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CSU Documentation

Prescribers

Pre-Admit

Who ShouldWho CouldScreenWorkflowCalMHSA User Guide
Pre-Admit
Front Desk All StaffClient Search (Create a new Client)Creating a New Client How to Create a New Client - 2023 CalMHSA
Documenting Inquiries
Front Desk Management / Nursing / PrescribersInquiryNavigating Inquiry Details Screen - Initial TabHow to Navigate the Client Inquiry Screen-Initial Tab - 2023 CalMHSA
Front Desk Management / Nursing / PrescribersInquiryDocumenting External Referrals How-to-document-an-incoming-referral-from-an-external-agency-optional/
Front Desk Management / Nursing / PrescribersInquiryDocumenting Phone Calls for TriageHow to Document Phone Calls for Triage - 2023 CalMHSA
Tracking Inquiries
Prescriber / ManagementFront Desk / NursingInquiries (My Office)Navigating Inquiries (My Office) ScreenInquiries (My Office) List Page - 2023 CalMHSA
Prescriber / ManagementFront Desk / NursingInquiries (My Office)Navigating Client Inquiries (Client) Screenhttps://2023.calmhsa.org/client-inquiries-list-page/
Prescriber / ManagementFront Desk / NursingInquiries (My Office)Referral TrackingHow to View Requests for Services that are Pending - 2023 CalMHSA

Documentation

Who ShouldWho CouldScreenWorkflowCalMHSA User Guide
Medical Documentation
Prescribers / Nursing / Mental Health Workers Caregiver SupportInterdisciplinary Treatment PlanCompleting Initial Treatment Plan how-to-complete-the-interdisciplinary-treatment-plan
Prescribers / Nursing / Mental Health Workers Caregiver SupportInterdisciplinary Treatment PlanReviewing / Updating Treatment Planhow-to-update-the-interdisciplinary-treatment-plan
PrescriberNursing Completing History and Physical Under Construction
PrescriberNursing Completing Initial Mental Status Exam (MSE)Under Construction
PrescriberNursing How to Complete the Psychiatric Evaluationhttps://2023.calmhsa.org/prescriber-how-to-complete-the-psychiatric-evaluation/

Orders

Who ShouldWho CouldScreenWorkflowCalMHSA User Guide
Navigating Client Orders
Prescribers / Nursing Caregiver SupportClient Orders (Client)Navigating Client Orders (Client) List PageIn Training Materials Folder: Needs to be Uploaded
Prescribers / Nursing Caregiver SupportOrders (My Office)Navigating Orders (My Office) List PageCalMHSA: Need to Create
Prescriber / NursingCaregiver SupportOrder Setup / Client Order (Client)Order Options: Order Can Be Completed In Training Materials Folder: Needs to be Uploaded
Prescriber / NursingCaregiver SupportOrder Setup / Client Order (Client)Orders Options: Order RationaleIn Training Materials Folder: Needs to be Uploaded
Prescriber / NursingCaregiver SupportOrder Setup / Client Order (Client)Orders Options: Order CommentsIn Training Materials Folder: Needs to be Uploaded
Prescriber / NursingCaregiver SupportOrder Setup / Client Order (Client)Orders Options: Diagosis RequiredIn Training Materials Folder: Needs to be Uploaded
Prescriber / NursingCaregiver SupportOrder Setup / Client Order (Client)Orders Options: Dual Sign RequiredIn Training Materials Folder: Needs to be Uploaded
Prescriber / NursingCaregiver SupportOrder Setup / Client Order (Client)Order Options:Self AdministeredIn Training Materials Folder: Needs to be Uploaded
Prescriber / NursingCaregiver SupportOrder Setup / Client Order (Client)Order Options: Pain Level Required?
Prescriber / NursingCaregiver SupportOrder Setup / Client Order (Client)Order Options: Multiple Admins Allowed Within Hour In Training Materials Folder: Needs to be Uploaded
Prescriber / NursingCaregiver SupportOrder Setup / Client Order (Client)Order Options: Whiteboard ObservationsIn Training Materials Folder: Needs to be Uploaded
Prescriber / NursingCaregiver SupportOrder Setup / Client Order (Client)Order Options: Whiteboard Legal In Training Materials Folder: Needs to be Uploaded
Prescriber / NursingCaregiver SupportOrder Setup / Client Order (Client)Order Options: Add Order to MARIn Training Materials Folder: Needs to be Uploaded
Nursing

Medication Management Rx

Thing You Want to DoWhat is It Called?
Where Can You Find It?
√Pro Tip
Send Medications to a Preferred PharmacyPreferred PharmacyCan select most common site and save for future use as a dropdown when you order a specific medication. Of note, the pharmacy will default back to preferred pharmacy even if a specific medication was previously ordered for a different pharmacy.
Record AllergiesAllergies/Intolerance/Failed TrialsRecommended to put allergies here because it will autopopulate in other parts of EHR.

If the allergy is in a similar drug class as a medication
you are trying to order, you will not be able to
prescribe ̶ switch the allergy to “intolerance” and/or
“failed trial.”
Review Active MedicationsMedication ListOf note, the current medication widget shows all medications including discontinued or voided. Can go to Medication List and filter for "current." Recommend saving filter as a favorite.
Review Past MedicationsMedication HistoryUse the right-hand side darker blue button (rather than the lighter blue one, which is for Surescript's most recent list of medication in their system)
Review medication
Consent
Consent HistoryUse the right-hand side darker blue button. The other
Order New MedicationsNew OrderUse the right-hand side darker blue button.
Add External MedicationsAdd MedicationCan add the source of the prescription, who is the prescriber
Change an Existing OrderSelect Checkbox of Existing Medication and Choose “Change Order”
Refill an Existing OrderSelect Checkbox of Existing Medication and Choose “Re-Order”Cannot do this if controlled substance and will need a new order
Patient Medication ConsentSelect Checkbox of Medication and Choose “Patient Consent”This will pull up a document that both prescriber and client can sign. Can select and sign multiple consents all at once.
Sign Verbal or Queued Outpatient Medication OrdersQueued/Verbal Orders Widget in Providers Dashboard --> RxThis will automatically connect you to the orders pending your review.
Review New/Changed MedicationsAfter clicking “Prescribe” button, a review screen will appear. If you approve, then choose “prescribe” a second time.Make sure you check the checkbox under “ready to sign.”
Approve Conrolled SubstancesOn review screen, after clicking “Ready to Sign” and “Prescribe,” you will be prompted on phone’s HID appSwipe "Approve" green button
Review Prescription StatusClick on a hyperlink of a medication name --> Script History -- Check “Status”Prescribers can view a history of multiple clients in
Start Page > Outbound Prescriptions.

If nurses are set up as prescriber proxy they can also
see prescription status (and refill request).
Establishing nurses as “prescriber” does not
mean they can prescribe without doctor approval;
medication orders will still go through the verbal or
queued order approval process.
Discontinue Existing MedicationMedication List; click the “X” at leftThis will then save in medication history with end date recorded and a pop-up will allow you to record the reason.
Mental Health Staff

Medication Management Rx

Thing You Want to DoWhat is It Called?
Where Can You Find It?
√Pro Tip
Send Medications to a Preferred PharmacyPreferred PharmacyCan select most common site and save for future use as a dropdown when you order a specific medication. Of note, the pharmacy will default back to preferred pharmacy even if a specific medication was previously ordered for a different pharmacy.
Record AllergiesAllergies/Intolerance/Failed TrialsRecommended to put allergies here because it will autopopulate in other parts of EHR.

If the allergy is in a similar drug class as a medication
you are trying to order, you will not be able to
prescribe ̶ switch the allergy to “intolerance” and/or
“failed trial.”
Review Active MedicationsMedication ListOf note, the current medication widget shows all medications including discontinued or voided. Can go to Medication List and filter for "current." Recommend saving filter as a favorite.
Review Past MedicationsMedication HistoryUse the right-hand side darker blue button (rather than the lighter blue one, which is for Surescript's most recent list of medication in their system)
Review medication
Consent
Consent HistoryUse the right-hand side darker blue button. The other
Order New MedicationsNew OrderUse the right-hand side darker blue button.
Add External MedicationsAdd MedicationCan add the source of the prescription, who is the prescriber
Change an Existing OrderSelect Checkbox of Existing Medication and Choose “Change Order”
Refill an Existing OrderSelect Checkbox of Existing Medication and Choose “Re-Order”Cannot do this if controlled substance and will need a new order
Patient Medication ConsentSelect Checkbox of Medication and Choose “Patient Consent”This will pull up a document that both prescriber and client can sign. Can select and sign multiple consents all at once.
Sign Verbal or Queued Outpatient Medication OrdersQueued/Verbal Orders Widget in Providers Dashboard --> RxThis will automatically connect you to the orders pending your review.
Review New/Changed MedicationsAfter clicking “Prescribe” button, a review screen will appear. If you approve, then choose “prescribe” a second time.Make sure you check the checkbox under “ready to sign.”
Approve Conrolled SubstancesOn review screen, after clicking “Ready to Sign” and “Prescribe,” you will be prompted on phone’s HID appSwipe "Approve" green button
Review Prescription StatusClick on a hyperlink of a medication name --> Script History -- Check “Status”Prescribers can view a history of multiple clients in
Start Page > Outbound Prescriptions.

If nurses are set up as prescriber proxy they can also
see prescription status (and refill request).
Establishing nurses as “prescriber” does not
mean they can prescribe without doctor approval;
medication orders will still go through the verbal or
queued order approval process.
Discontinue Existing MedicationMedication List; click the “X” at leftThis will then save in medication history with end date recorded and a pop-up will allow you to record the reason.
Caregiver Support

Medication Management Rx

Thing You Want to DoWhat is It Called?
Where Can You Find It?
√Pro Tip
Send Medications to a Preferred PharmacyPreferred PharmacyCan select most common site and save for future use as a dropdown when you order a specific medication. Of note, the pharmacy will default back to preferred pharmacy even if a specific medication was previously ordered for a different pharmacy.
Record AllergiesAllergies/Intolerance/Failed TrialsRecommended to put allergies here because it will autopopulate in other parts of EHR.

If the allergy is in a similar drug class as a medication
you are trying to order, you will not be able to
prescribe ̶ switch the allergy to “intolerance” and/or
“failed trial.”
Review Active MedicationsMedication ListOf note, the current medication widget shows all medications including discontinued or voided. Can go to Medication List and filter for "current." Recommend saving filter as a favorite.
Review Past MedicationsMedication HistoryUse the right-hand side darker blue button (rather than the lighter blue one, which is for Surescript's most recent list of medication in their system)
Review medication
Consent
Consent HistoryUse the right-hand side darker blue button. The other
Order New MedicationsNew OrderUse the right-hand side darker blue button.
Add External MedicationsAdd MedicationCan add the source of the prescription, who is the prescriber
Change an Existing OrderSelect Checkbox of Existing Medication and Choose “Change Order”
Refill an Existing OrderSelect Checkbox of Existing Medication and Choose “Re-Order”Cannot do this if controlled substance and will need a new order
Patient Medication ConsentSelect Checkbox of Medication and Choose “Patient Consent”This will pull up a document that both prescriber and client can sign. Can select and sign multiple consents all at once.
Sign Verbal or Queued Outpatient Medication OrdersQueued/Verbal Orders Widget in Providers Dashboard --> RxThis will automatically connect you to the orders pending your review.
Review New/Changed MedicationsAfter clicking “Prescribe” button, a review screen will appear. If you approve, then choose “prescribe” a second time.Make sure you check the checkbox under “ready to sign.”
Approve Conrolled SubstancesOn review screen, after clicking “Ready to Sign” and “Prescribe,” you will be prompted on phone’s HID appSwipe "Approve" green button
Review Prescription StatusClick on a hyperlink of a medication name --> Script History -- Check “Status”Prescribers can view a history of multiple clients in
Start Page > Outbound Prescriptions.

If nurses are set up as prescriber proxy they can also
see prescription status (and refill request).
Establishing nurses as “prescriber” does not
mean they can prescribe without doctor approval;
medication orders will still go through the verbal or
queued order approval process.
Discontinue Existing MedicationMedication List; click the “X” at leftThis will then save in medication history with end date recorded and a pop-up will allow you to record the reason.
Front Desk

Medication Management Rx

Thing You Want to DoWhat is It Called?
Where Can You Find It?
√Pro Tip
Send Medications to a Preferred PharmacyPreferred PharmacyCan select most common site and save for future use as a dropdown when you order a specific medication. Of note, the pharmacy will default back to preferred pharmacy even if a specific medication was previously ordered for a different pharmacy.
Record AllergiesAllergies/Intolerance/Failed TrialsRecommended to put allergies here because it will autopopulate in other parts of EHR.

If the allergy is in a similar drug class as a medication
you are trying to order, you will not be able to
prescribe ̶ switch the allergy to “intolerance” and/or
“failed trial.”
Review Active MedicationsMedication ListOf note, the current medication widget shows all medications including discontinued or voided. Can go to Medication List and filter for "current." Recommend saving filter as a favorite.
Review Past MedicationsMedication HistoryUse the right-hand side darker blue button (rather than the lighter blue one, which is for Surescript's most recent list of medication in their system)
Review medication
Consent
Consent HistoryUse the right-hand side darker blue button. The other
Order New MedicationsNew OrderUse the right-hand side darker blue button.
Add External MedicationsAdd MedicationCan add the source of the prescription, who is the prescriber
Change an Existing OrderSelect Checkbox of Existing Medication and Choose “Change Order”
Refill an Existing OrderSelect Checkbox of Existing Medication and Choose “Re-Order”Cannot do this if controlled substance and will need a new order
Patient Medication ConsentSelect Checkbox of Medication and Choose “Patient Consent”This will pull up a document that both prescriber and client can sign. Can select and sign multiple consents all at once.
Sign Verbal or Queued Outpatient Medication OrdersQueued/Verbal Orders Widget in Providers Dashboard --> RxThis will automatically connect you to the orders pending your review.
Review New/Changed MedicationsAfter clicking “Prescribe” button, a review screen will appear. If you approve, then choose “prescribe” a second time.Make sure you check the checkbox under “ready to sign.”
Approve Conrolled SubstancesOn review screen, after clicking “Ready to Sign” and “Prescribe,” you will be prompted on phone’s HID appSwipe "Approve" green button
Review Prescription StatusClick on a hyperlink of a medication name --> Script History -- Check “Status”Prescribers can view a history of multiple clients in
Start Page > Outbound Prescriptions.

If nurses are set up as prescriber proxy they can also
see prescription status (and refill request).
Establishing nurses as “prescriber” does not
mean they can prescribe without doctor approval;
medication orders will still go through the verbal or
queued order approval process.
Discontinue Existing MedicationMedication List; click the “X” at leftThis will then save in medication history with end date recorded and a pop-up will allow you to record the reason.
Management

Medication Management Rx

Thing You Want to DoWhat is It Called?
Where Can You Find It?
√Pro Tip
Send Medications to a Preferred PharmacyPreferred PharmacyCan select most common site and save for future use as a dropdown when you order a specific medication. Of note, the pharmacy will default back to preferred pharmacy even if a specific medication was previously ordered for a different pharmacy.
Record AllergiesAllergies/Intolerance/Failed TrialsRecommended to put allergies here because it will autopopulate in other parts of EHR.

If the allergy is in a similar drug class as a medication
you are trying to order, you will not be able to
prescribe ̶ switch the allergy to “intolerance” and/or
“failed trial.”
Review Active MedicationsMedication ListOf note, the current medication widget shows all medications including discontinued or voided. Can go to Medication List and filter for "current." Recommend saving filter as a favorite.
Review Past MedicationsMedication HistoryUse the right-hand side darker blue button (rather than the lighter blue one, which is for Surescript's most recent list of medication in their system)
Review medication
Consent
Consent HistoryUse the right-hand side darker blue button. The other
Order New MedicationsNew OrderUse the right-hand side darker blue button.
Add External MedicationsAdd MedicationCan add the source of the prescription, who is the prescriber
Change an Existing OrderSelect Checkbox of Existing Medication and Choose “Change Order”
Refill an Existing OrderSelect Checkbox of Existing Medication and Choose “Re-Order”Cannot do this if controlled substance and will need a new order
Patient Medication ConsentSelect Checkbox of Medication and Choose “Patient Consent”This will pull up a document that both prescriber and client can sign. Can select and sign multiple consents all at once.
Sign Verbal or Queued Outpatient Medication OrdersQueued/Verbal Orders Widget in Providers Dashboard --> RxThis will automatically connect you to the orders pending your review.
Review New/Changed MedicationsAfter clicking “Prescribe” button, a review screen will appear. If you approve, then choose “prescribe” a second time.Make sure you check the checkbox under “ready to sign.”
Approve Conrolled SubstancesOn review screen, after clicking “Ready to Sign” and “Prescribe,” you will be prompted on phone’s HID appSwipe "Approve" green button
Review Prescription StatusClick on a hyperlink of a medication name --> Script History -- Check “Status”Prescribers can view a history of multiple clients in
Start Page > Outbound Prescriptions.

If nurses are set up as prescriber proxy they can also
see prescription status (and refill request).
Establishing nurses as “prescriber” does not
mean they can prescribe without doctor approval;
medication orders will still go through the verbal or
queued order approval process.
Discontinue Existing MedicationMedication List; click the “X” at leftThis will then save in medication history with end date recorded and a pop-up will allow you to record the reason.
QA