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Phase I User Manual - Welcome to the Stars Behavioral Group

1. lt nM Ede L E Program Community MH Services From 04 21 2007 12 00pm Enter New Service 7 Schedule Service F Service De Date Schedule Date Time Actual Date Time Durkin Saf E f M E AE V octe Y VCS 6 month update H E e idal Rehabilitation SCS Discharge 4 Individual Rehabilitation Z Referrals Scanned Documents i Nate 2 My Progress Notes 5 Plan Development Targeted case management E a Hep SWC5 Discharge Referrals Scanned Documents My Progress Notes Service has been electronically signed by staff Service has been submitted and approved by supervisor J E Service has been submitted to supervisor for approval Service has NOT been electronically signed by staff in draft Service has NOT been submitted to supervisor in draft See Icon Table on next page for more detailed information on what each icon indicates SBHG EMR Training Phase Page 32 of 50 volume IV l K C4 18 Gyo W t B H ia Icon Table The pencil icon indicates the service is saved in draft format and has not been submitted for approval You able to modify this service while draft format Do not leave services in draft format for more than a week When services remain in draft format they do not get billed Use the Submit Button to forward services to your supervisor or designee for approval Your electronic signature will be at
2. Addams Charles siFiis44 0000203808701 2007 MIS NUMBER Addams Cousin Itt 1 1 1901 ooooz036 05 01 2007 MIS NUMBER Addams Digit i7107 00007046 02 14 2007 MIS HUMBER Addams Gomez 45 1888 00002039 06 0112007 MIS HUMBER Addams 12 4 1880 00002035 01 1 01 2007 MIS grandmama HUMBER Addams Lurch 171 1801 ooooz043 o4f21f2007 MIS LUMBER SBHG EMR Training Phase Page 11 of 50 volume IV Locate your training client and click on their name Notice the client s name and demographic information now populates in the parent selection bar within the main interface es Yer 5 1 20 Training Copy of ENOL a oa re Agency Stars Behavioral Health Group Office Stars Behavioral Health Group Regional Office User MHS 10 a Referral EE Incidents Outreach Reports Select Client fddams Lurch DOB 01 01 1801 Age 207 E ID 00002043 Intake 04 21 2007 11 Cemetery Lane Los Angeles CA 90021 CD 8 Client Information Personal Information Critical Information Relationships Health Information Billing Authorization Case Management Service Management Plan Development Health Information Progress Notes Referrals To Your Agency To Your Programs To External Agencies Reports Reports Determining if there is a Treatment Plan 1 On the navigation bar under Case Management click on Plan Development 2 Click on Treatment Plan 3 If there is not a Treatment Plan you will see l
3. System Entry Dake Mote Paragraph Font xB 7 Ube SBHG EMR Training Phase I Page ge 35 of 50 volume IV A closer look at the Notes Information section Date Time is the date and time of day the addendum is written The system will auto populate the current date and time You are able to change the data if needed Y ADD Form Webpage Dialog x l Motes Addams Charles DOB 04 05 1988 _ KD eh Print lt Close El Notes Information Date Time 02 08 2009 EAE Time 08 33 FM Staff Bi Staff Duration Staff click the ellipses to the System Entry Date far right and select your name Mote from the staff drop down box Paragraph v Font Xv Size v Y EA ESR BIU BS PS Staff Duration enter the duration of time it took to document the addendum Enter the duration in minutes This time DOES NOT count toward your productivity and the time does not get billed e To enter the time click in the field next to the words Staff Duration System Entry Date not modifiable the system auto generates this date and time when the addendum is entered The Note section functions the same as outlined on page 27 An addendum to a Progress Note does not need to be written in any particular format it can be written in narrative format SBHG EMR Training Phase Page 36 of 50 volume IV When you have completed the Notes Information section and the Progress Note doc
4. your Center Coordinator Change a diagnosis for Clinician complete a my client Change of Diagnosis form and give it to the Center Coordinator then trigger a Change of Diagnosis service in the EMR notify Psych of Diagnosis change I am working with a Supervisor notifies the client from a different Center Coordinator team and need access to that client Center Coordinators change Diagnosis in the EMR AND the IS system Center Coordinators add staff as a Direct Worker to the client in the EMR if the staff needs access to more than one client on a particular team contact the EMR team to have the staff added to that teams workgroup Center Coordinators add work groups to clients Adding work groups SBHG EMR Training Phase Page 44 of 50 volume IV Problem Adding School Information Entry Allotted time for billing particular services forms Appropriate billing codes Audit issues my packet forms are on the QA Audit list Packet questions I am confused about the packet process Problem with the Treatment Plan Staff Responsibility Clinician complete a Collateral Information Sheet and give it to your Center Coordinator Clinician contact your supervisor the QA Dept or review the Scope of Practice Manual Clinician contact your supervisor the QA Dept review the Scope of Practice Manual or review the help button within each service in th
5. Billing Authorization a Referrals Made To Programs To External Sources Program Enrollments Navigation Bar SBHG EMR Training Phase Page 6 of 50 volume IV MODULES Each MODULE represents a point of entry for a separate business function Some of the information may be repeated from one module to another i e Referral personal demographics would be the same information in Client personal demographics Updating one area will filter to other areas Reterral Client Incidents Gutreach Reports The module you are currently working in will appear in gray with a slightly larger font Active Module All inactive modules will have a black background and slightly smaller font Referral Module DAA When you first login to the main interface you will be defaulted to the REFERRAL MODULE tab on the Parent Selection Bar You could locate your client in the referral module however you will not be able to capture billable services provided The PARENT SELECTION BAR indicates the client s name and demographic information Beneath the Parent Selection Bar in the Main section will be information regarding the client family incident etc Click on the CLIENT MODULE tab Notice the client module tab is now grey and bigger font Outreach Reports Select Client DOB The CLIENT MODULE is used to access and track information about people who are clients Some of the following pieces of information ca
6. Safety plan School Consultation For IEP Targeted case management TBS Referral Screening SBHG EMR Training Phase Page 16 of 50 volume IV ENTERING A NEW SERVICE This is where you will document ALL services provided for your client s except the Treatment Plan which is explained in the Phase II manual This will open a drop down list of services within the First click on Enter New Service scope of practice of the staff For this training each login has the same scope as a Mental Health Specialist II or III As mentioned on page 14 if you are an MHS I or a Support Counselor your Enter New Service drop down list will contain those services within your scope of practice However all staff no matter their title will be able to view every service that has been entered by everyone working with the client Referral CHEAT Incidents Gutreach Reports gt Select Client Sddams Lurch DOB 01 01 1801 Age 207 E ID 00002043 Intake 0 E Client Information jie Service Management Personal Informatio Critical Information Relationships sve sic SYC S CS Annual update E Health Information Physical Characteristics Diagnoses Information gt v Treatment History is Program Community MH Services From 04 21 2007 12 00pm kI Enter New Service 1e Schedule Service Substance Use aleae Service Due Date Scheduled Date Time Actual Date Time Duration Staf Medications 2 Targeted case management 03 06 2008 04
7. back in Track IT for the disposition of the ticket Problem I need to delete a scanned packet only requested by Center Coordinators or MR dept I have moved to a different team and need access to my new team Unable to save a service form I keep getting an error message I have promoted to an MHS II I need access to the appropriate scope of practice in the EMR Staff Responsibility Clinician contact your new supervisor Clinician troubleshoot that all required fields are complete make sure there is not any symbols amp etc in the text fields make sure that you DID NOT cut and paste from word or that you completely added information in the participants field etc Clinician when requested provide another signature to the EMR dept with new title degree SBHG EMR Training Phase Page 48 of 50 volume IV Center Coordinator Quality Assurance Department Responsible Sos 2 gt 5 2 N lt Q lt P S om A lt P lt Q Q Medical Records Note to Department Responsible Center Coordinator Medical Records Dept completes a Scan Packet Deletion request form and submits it to the EMR Dept EMR Dept will delete the scanned packet upon receipt of the deletion request form Supervisor needs to send a Track IT ticket to the EMR team EMR Team will assign the staff to the new team Supervisor assists staff with trouble shootin
8. login you ll immediately see your My Evolv page This will be your site navigation short cut page For more information regarding My Evolv page please reference the Other EMR Functions Manual But first let s get familiar with the components of the Evolv CS Workspace er 5 1 20 Training Copy of Production 1 29 2008 My VOLV Refres t Return to Main og Off My Alerts My Tasks No unread alerts are available at this time No tasks are due at this time My Groups My Clients No Groups are assigned to you at this time Full Name BirthDate ID Intake Dt Last Service Dt Addams Grandmama 12 04 1880 00002035 01 01 2007 12 00PM 06 05 2008 Munster Marilyn 01 01 1933 00002048 11 05 2007 12 00PM 04 30 2008 My Pending Referrals No Pending Referrals are available Look at the top of the page and click on Return to Main This section will demonstrate how to move around the system It will introduce some basic terminology essential to the operation by all levels of users including administrators through intake workers og Fer 5 1 20 Training Copy of Production 1 29 ENOL 200 all Agency Stars Behavioral Health Group Office Stars Behavioral Health Group Regional Office User MHS 10 i Referral Client Incidents Outreach Reports Select Referral DOE E Agency Referral Referral Information Relationships Health Information Modules Task Bar alee does Parent Selection
9. on the persons name SBHG EMR Training Phase Page 23 of 50 volume IV Continued look at the required fields Completed Information Actual Date Time klti End Date Time System Generated Face to Face Time hhmm Other Time hh mm Total Time hhmm Number of Family Collaterals Number of Non Family Collaterals Evidence Based Practice Time Completed By Poud Angla Submit To Service Site UECOE Service Site Indicates the location where you provided the service To select the Service Site 1 Click on the Service Site button Service Site A drop down description list will Appear 2 Click on the location NOTE Do not select Facility Vehicle or Staff Vehicle as a location If a service is provided while in your vehicle select Other Outing Location or Public Setting instead Once you click on the location the short cut number automatically populates the field and the description name appears next to the field Outcome is not a required field you do not need to enter any data in this field SBHG EMR Training Phase Page 24 of 50 volume IV This is a VIEW ONLY example of where you would see the Diagnosis and Impairments Barriers in the Service Entry form Changes can NOT be made to these fields You have the ability to reference this information when writing your progress notes If the Diagnosis needs to be changed an MHS II or III MUST complete a Change of Diagnosis f
10. problem can wait you can sign up for EMR Support from the EMR Dept sign up sheet at the receptionist desk in each office NOTE Bring your EMR Manual with your for all trainings Clinician use the submit to button as directed by your Supervisor and Center Director Clinician send a Track IT ticket to the EMR Dept Clinician send a Track IT ticket to IT Dept Clinician send a Track IT ticket to IT Dept Clinician send a Track IT ticket to IT Dept Department Responsible Center Coordinator Quality Assurance Center Director Supervisor EMR Team C ee a ee SBHG EMR Training Phase Page 46 of 50 volume IV Note to Department Responsible Supervisor assist your staff with navigation questions if you have any questions problems contact the QA Dept QA Dept assist with navigation questions problems as needed if you have any questions problems send a Track IT ticket to the EMR Dept EMR Dept will respond to ticket in Track IT Center Directors work with supervisor to instruct staff to use the submit to button while supervisor is out EMR Team will un submit service back to staff Supervisor work with the QA Dept and Center Directors to identify relevant reports in the EMR IT Dept will respond through Track IT IT Dept will respond through Track IT IT Dept will respond through Track IT Problem I need a service deleted Clinician contact y
11. will open showing ALL locations where Community MH Services can be provided select the location HINT since most of the facilities begin with STARS it would be easier to select the correct Facility based on the address b Important A BE VERY careful in selecting the correct Facility or the service will be billed incorrectly SBHG EMR Training Phase Page 26 of 50 volume IV Scroll down to the Progress Note Section just below the Facility Providing Service button You are able to type a narrative note by clicking in the progress note area OR you are able to select a progress note template that will auto populate El Service Related Encounter Information Program Providing l Service LMHS Community MH Services Facility Providing 00543 ooo l l Service olats Star View Communit Service Authorization Services LB Lic 00543 E Progress Note Mote e ru 1a A To select a Progress Note template click on the template icon Eel A drop down list of templates will open Select the desired template Type in the content of your note under the IGBIRP template headers Text Template Webpage Dialog Template Name nero ee Wr Close None Paragraph sid Font o Size w BIRF A Care Plan PN Template Introduction GenerallCase Mamti Rehabi Nursing PN Oasis IGBIRP Goal Intervention Response Plan SBHG EMR Trainin
12. 00pm 0107 10 MHS SOU Case Consultation 01 01 2008 12 00pm 00 47 10 MHS Case Management No Contact NIC Note S C5 Service Managemen 9 07 EN 2 Individual Therapy 042112007 03 45pm 01 39 10 MHS SVCS Admission I SCS Discharge VE 06 13 2007 12 08pm 01 18 10 MHS ma Enter New Ger isn Schedule Geevire m CAFAS Results L Case Consultation i Collateral Contact A Crisis Intervention 0 Documentation Family Collateral k Next Select k o FF Indpendent living stills scall 1 55 L No Show Canceled Plan Development Reschedule Safety plan 4 School Consultation for IEF Targeted case management TBS Referral Screening SBHG EMR Training Phase Page 17 of 50 volume IV A Service Entry form will open where the service and billing information will be entered ADD Form Webpage Dialog SVCS Simple Service Entry Client Comer Teresa DOB 08 09 1993 ID 00003481 Intake 11 07 2008 12 00am Be aare e Cancel eh Print No Show Information County 19 19073568 User Help File Exempt from Biling No Show Attempt to Gonbect i El Encounter Information Entered With Agency Flacement 11 07 2008 12 00am Type Individual Rehabilitation Activity Type Time Encounter wiks m Items in BOLD are required fields e a You will not be able to save the Actual DateTime S Ti
13. AS Discharge Summary Aftercare Plan 4 Psychiatric Referral Worksheet Family Safety Crisis Plan Substance Use Assessment DD OMH 553 Family Therapy 5 Substance Use Parent CG Questionaire OMH 552 Independent living skills scale IL55 9 07 substance Use Self Evaluation DD DMH 554 Individual Rehabilitation f Suicide Assessment L4 Individual Therapy No Contact M C Note 4 Permanancy Placement Screening 4 Trauma Screening Plan Development SVCS 6 month update L4 Provisional Care Plan Psychiatric Referral Worksheet Service Integration Team SIT f Substance Use Assessment DD DMH 553 Substance Use Parenti CG Questionaire OMH 552 f Substance Use Self Evaluation DO OMH 554 Suicide Assessment CARAS Results 4 Coordination Flan PECFAS Permanancy Placement Screening 4 Psychiatric Referral Worksheet C Treatment Team Cy Targeted case management Trauma Screening SVCS Annual update Cy Treatment Team Annual Assessment Update L CAFAS Results Ci Community Functioning Evaluation SVCS Di S ch ar g e Coordination Plan Dangerous Behavior Screening Administrative CAFAS rev 9 07 Independent living skills scale L55 9 07 Administrative DIC Summary Aftercare Plan 4 PECFAS 4 Administrative PECFAS Psychiatric Referral Worksheet CARAS Results Service Integration Team SIT Discharge Summary Af
14. EMR Training Phase Page 40 of 50 volume IV Attempt 2 H Z find all values that start with H I J X Y or Z i e h through z F Event Definitions with Security Client Web Page Dialog f x EventName IHZ category o Is Service None HBIG Hepatitis B Immune Globulin Immunizations Health Statement Requirements for People Hearing Exam Health Hep A Hepatitis A Immunizations Hep E Hepatitis B Immunizations Hib Haemoplilus influenzae type b Immunizations Records begin with H HIV AIDS Group Training Yes HIV Antibody Lab Tests No HIV PCR Lab Tests No HIV AIDS History Test Assessments for People Yes Home Visit Placement Disruptions No Home Visit Activities Yes Housing Support Activities Other Yes Tn Hame Treatment lDlarement and Treatment Hietarw Na Ma First 100 records out of 142 displayed A Event Definitions with Security Client Web Page Dialog fx EventName HHZ Is Service Psychiatrist Certifications for People Na Psychosocial Requirements for People No Psychotherapy Activities Yes Putative Father 1 Parental Rights Terminated Legal History for People Yes Putative Father 2 Parental Rights Terminated Legal History for People Yes Quartlerly Review Treatment Service Plans for People Mo Recreation Therapy Activities Yes Referral Data Collection Form Test Assessments for People Na
15. Referral to another Agency Referrals Made to Programs or Gut Yes Referral to Program Internal Referrals Made to Programs or Gut Yes Referral to Program from Outside Source Referrals Made to Programs or Gut No Referrals to the Agency Referrals to Agency No Registered Nurse Certifications for People No Regulations and Statues on Child Day Care Training No Resources Group Training Yes Ill Ea First 100 records out of 142 displayed Attempt 3 R Z etc This makes it possible for users to filter through all possible ranges of listed records SBHG EMR Training Phase Page 41 of 50 volume IV Service Grid Supervisor PN review Objective Link Needed PB required P Treatment Context 1 3 page Child Assessment Administrative Discharge Summary Aftercare 2 Plan 3 Adult Initial Assessment 4 Adult Initial Assessment Addendum 5 Adult Substance Use Self Evaluation 6 Annual Assessment Update 7 CAFAS 8 Care Plan 9 CFE 10 Change of Diagnosis 11 Child Initial Assessment No 12 Child Initial Assessment Addendum No 13 Coordination Plan No 14 Dangerous Bx Safety Plan supervisor completes Yes 15 Dangerous Bx Screening 16 Discharge Summary Aftercare Plan 17 Family Safety Crisis Plan Yes Yes No 18 ILSS Screening No No No 1 i 21 22 Service Integration Team SIT No Yes No 3 24 5 a 27 Suicide Safety Plan supervisor completes Yes No No 28 TBS Functional Asses
16. SBHG EMR Training Phase User s Guide PART EVOLV SYSTEM CONVENTIONS PART II ENTERING A SERVICE Volume IV Release Date 2 8 09 TABLE OF CONTENTS Part Evolv System Conventions learning ODje CtIVES cccccccsssssssctsceecesssseesseesetetsssesseseesesssseses 2 SYSTEM Log OMN ccccccccsssccccnsssescsccccccssssencenecessscccaccccecescrs sss oo aani 3 HOME USG ccscscssccccrsssssssssscccccsseeeescesccccecceeees coe na 3 Checking the Latest News and Update LINK ceeesssssssecseceeceeceecescesceesesseecessesesseceuaeesees 4 Logging into the EMR 0c 0 00s0 000 _f IEEE ss cscs hl 5 My Evolv Page ccccccserersrse1ss gif EPP osc sseceerssssssstesaaecrierers ress A 6 Basic NavVigatiOnn 0 0 00 0 caftMMMMs csccccsssssssscssceccssssesescoscccceseeeesesescoeess Mm zm 6 Vee ee 7 Documenting Non Billable services on a Referall cccccccesssssceeseesessesessseeeescescesseeseeseesens 8 Part Il Opening a Client DIERRIRIIIIIT ccccccscssssssetesressccssessssss ea 10 Selecting a ClCNMRIIIMMMEET csssssscssssccsess ss lll 12 Determining if a Treatment Plan and or Collaterals are on file in the EMR 00 12 Entering a Service with the Client MOdUule ccccssesssssssssssssceecesceecescescessessesceesessesensens 13 List of services under Service Management Navigation cccccccessssssssssssseesesevesesessesees 14 Deta eCe En
17. Training Phase Page 21 of 50 volume IV Continued look at the required fields Completed Information Actual Date Time Ol Time End Date Time System Generated Face to Face Time hhmm Other Time hh mm Total Time him Number of Family Collaterals Number of Non Family Collaterals Evidence Based Practice Completed By Sumit To Service Site Outcome Other Time is Service Documentation Travel Service is defined any time the client is NOT present for the service Examples Collateral Targeted Case Management Case Consultation services etc provided WITHOUT the client present NOTE Enter time in minutes The system automatically changes it to hours and minutes ex 63 minutes would appear as 1 03 Total Time the system Auto Adds Face to Face and Other Time and populates this field automatically with the total when the service is saved You can not change this time Number of Family and Non Family Collaterals you must indicate the number of Family and Non Family collaterals present during your session Client is not counted in the number of Family Collateral Staff providing service is not part of any count Examples of Non Family Collaterals would be any person that the client family or staff considers an integral part of the client s treatment i e CSW PO etc If there are no Family or Non Family Collaterals present enter 0 in both fields Evidence Based Practi
18. Workspace Navigate through Modules in the Evolv CS System oe fT SYSTEM LOG ON As with all database systems you will have to log on to the system to identify yourself To open the EMR portal page from within a SBHG location type EMR into an Internet Explorer browser window Home USE To open the EMR portal page outside the SBHG network i e working from home type into an Internet Explorer browser window If you have difficulties logging into the EMR ori a computer that is not an SBHG Starview computer you will need to reference the Home User s Guide located in your EMR Manual The EMR and IT team is not allowed to help staff with computer issues outside the SBHG network 6 defran systems Live Environment Training Environment SBHG EMR Training Phase Page 3 of 50 volume IV Click on the link listed below Check this link often for the latest news and updates with the EMR This is the EMR Teams way to communicate with all staff When you click on the link a new Internet Explorer page will open Scroll down the page and review the information There are three sections to the Update Page EMR Tips amp Tricks EMR Myths EMR Enhancements To return to the EMR portal page click the Internet Brower back button z Hi j wt ps icnisweb starsinc comfupdatesfemrnews htm DEJ Fie Edit view Favorites Tools Help Links 4 Customize Links Free Hotmail P Outlook web Access gi RealPlay
19. ation Progress Notes Referrals To Your Agency To Your Programs To External Agencies Reports Reports E Lase Management ce Management Click on Service Entry Sym SYS Admission II SCS 6 month update SYES Annual update SYES Discharge Referrals Scanned Documents My Progress Motes SBHG EMR Training Phase Page 13 of 50 volume IV A closer Look at Navigation access within Service Management Here is a list of forms services under Service Management for MHS II access NOTE MHS and Support Counselor level access will differ based on Scope of Practice Service Entry E Case Management SVCS Admission I 4 Coordination Plan Provisional Care Plan o C 90801 0 5 Assessment PN MAT FSP 4 90802 0 5 Assessment PH MATIFSP 2 Administrative DIC Summary Aftercare Plan SWS Admission I SVS 6 month update SVS Annual update LY Annual Assessment Update CARAS Results 4 Case Consultation SVCS Admission II SSIs D Change of Diagnosis 3 page Child Assessment 4 child Initial Assessment A Adult Initial Assessment Child Initial Assessment Addendum CAFAS Results Collateral Contact 4 Child Initial Assessment C4 Community Functioning Evaluation LY Community Functioning Evaluation L4 Coordination Plan L Dangerous Behavior Screening Crisis Intervention Independent living skills scale IL553 9 07 Dangerous Behavior Screening PECF
20. bpage Dialog Client Addams Lurch DOB 01 0 1 1501 ID 00002043 Intake 04 71 2007 12 00pm Ll Save eo Cancel ElNo Show Information C a County Ib MIS NUMBER Exempt from Billing Mo show Attempt ta contact P p i M Click on the User Help File button e al A separate internet explorer window will open To close the window click on the red button Individual Rehabilitation Microsoft Internet Explorer provided by SBHG Ele L http ficemsmeb2 evaly_csjuser_help Service_Pragress_Nate htm i mywebsearch Search CD Smiley Central im Screensavers gt Cursor Mania E Fun Cards Links Customize Links g Free Hotmail P Outlook Web Access g RealPlayer f Starbase DA Track IT j Windows WS Windows Marketplace Windows Media E BA ames Orns Ewe gt iea RD eens s e wow R Bo Arlie T A y a Aaaa Individual Rehabilitation EPSDT Manual page 12 13 SKILL BUILDING e Detined as a senace actrmty that inclides assistance m improving maintaimng or restoring a chent s functional skulls as it relates to the Mental He condition of the chent Assists the chent in living independently Inchides activities that are designed to enable the chent to overcome thei limitations due to their mental disorder Teach the chent te function in an age appropriate manner without the need for redirection or intervention MUST match the objectivets in
21. ce not a required field at this time you do not need to enter any data SBHG EMR Training Phase Page 22 of 50 volume IV Continued look at the required fields Completed Information Actual Date Time End Date Time System Generated Face to Face Time hhmm Other Time hh mm Total Time hhmm Number of Family Collaterals Number of Non Family Collaterals Evidence Based Practice Completed By oyd Angeli Submit To Service Site Outcome Completed By When you log into the EMR with your user name and password and enter a service it will auto populate this field with your name DO NOT change this field BEWARE If you share your user name and password with somebody your name will show here as if you documented the service You are then responsible for any information entered DO NOT share your user name and password it s a violation of HIPAA and against company policy Submit To this is where you identify who this service will be submitted to for approval If submitting this service to your supervisor leave this field alone it will automatically submit to your supervisor by default If you need to submit this service to someone other than your supervisor 1 click on the Submit To button Submit To a drop down list of names will appear type in the last name or first name of the identified person Click the search button the persons name will show click
22. cking on the service El Program Community MH Services From 12 01 2006 12 00am Enter New Service 47 Schedule Service Service Due Date Scheduled Date Time Actual Date Time Duration Staff a 4 f mM El Individual Rehabilitation Fal 01022009 09 30am 02 15 2 MHS A No Contact NIC Note S 12 26 2008 02 00pm 01 00 2 MHS A Individual Rehabilitation 12 01 2008 09 00am 02 20 3 MHS zj Individual Rehabilitation 12 01 2008 09 00am 02 20 2 MHS Zj 1 Individual Rehabilitation 12 01 2008 01 00am 02 20 Depending upon the service provided one of two icons will appear to the right of the service entered a submit button or electronic signature button see next page for more explanation The service you selected Individual Rehabilitation requires supervisor s approval so you must click the envelope to the right of the service SBHG EMR Training Phase Page 31 of 50 volume IV SUBMITTING A SERVICE VS ELECTRONICALLY SIGNING A SERVICE To forward a service for approval simply click the submit button located to the right of the service entered Your electronic signature will be attached to this service upon submission to your supervisor To electronically sign a service that does not require your supervisors approval simply click the pencil icon located to the right of the service entered For the list of forms services that require submitting to your supervisor vs an electronic signature from you re
23. d your EMR session click on the log out button located in the upper right of your screen Wag xe Erl a oy web Searc pr is Marketplace Windows Media z gt Ea oe fm v oso Page CF Tool rowe 1 Cle Ig IE Do not click the Red X to close the EMR doing so will only close your internet browser NOT your EMR session You MUST close the door by clicking the log out icon SBHG EMR Training Phase Page 39 of 50 volume IV SEARCH TIPS Topic Look Up Tables with over 100 records Problem Users frequently believe that a record they are looking for does not exist or can not be found failing to realize that pick lists only list the first 100 records out of the total amount if there are over 100 This is a system convention that is used in Evolv CS to prevent potential performance issues Solution If the user does not know the first few letters of a field to search on the user can utilize different combinations of SQL keywords to filter the list Attempt 1 0 Z the number zero through the letter z equivalent to using the character as a wildcard Event Definitions with Security Client Web Page Dialog EventName 02 Category o O Is Service None l l 392 Petition Legal History for People No Achenbach Results Test Assesements for People Yes ACSW Certifications for People No Action Plan Review Treatment Servic
24. e EMR Clinician contact your supervisor Clinician contact your supervisor Clinician contact your Supervisor or your QA Manager Coordinator Department Responsible Center Coordinator Quality Assurance ee Center Director SBHG EMR Training Phase Page 45 of 50 volume IV Note to Department Responsible Center Coordinators add School information Supervisor or QA Dept review Scope of Practice Manual with staff Supervisor or QA Dept review Scope of Practice Manual with staff Supervisor review the audit issues with your staff if you have any questions problems contact the QA Dept QA Dept review the audit report with supervisors as needed Supervisor review the packet process with your staff if you have any questions problems contact the QA Dept QA Dept review the packet process with supervisors as needed Supervisor review the packet process with your staff if you have any questions problems contact the QA Dept QA Dept review the packet process with supervisors as needed Problem I need more help with navigating the EMR EMR coverage for Supervisor s on leave I accidently forgot to submit my service to someone other than my supervisor I am need to run reports in the EMR I keep getting logged off the EMR I get Internet error messages when I am in the EMR EMR is running slow Staff Responsibility Clinician contact your supervisor if the
25. e Plans for People No Additional Disposition Legal History for People Yes Adolescent Group Training Yes Adoption Group Training Ives Records may begin with s gt Adoption Court Appeal Legal History for People Yes Adoption Court Hearing Legal History for People Yes Adoption Disrupted Adoption Activities Yes Adoption Subsidy Requested Adoption Activities Yes Adult Education Group Training l p Yes Agency Plan Review Treatment Service Plans for People No Alternative Blarement lDiarement and Treatment Hietnrw Ihr First 100 records out of 235 displayed Event Definitions with Security Client Web Page Dialog Event Name category o Is Service Foster Parent Orientation Freed for Adoption Legal History for People General Counseling Activities Generic Intake Materials Test Assessments for People Generic Referral Materials Test Assessments for People Group Case Management Group Activities Group Counseling Group Activities Group Enrallment Memberships Placement in Profiles Group Therapy Group Activities HEIG Hepatitis B Immune Globulin Immunizations Health Statement Requirements for People Hearing Exam Health _ Hep A Hepatitis A Immunizations Hep B Hepatitis B l Immunizations Hib Haemoplilus influenzae type b Immunizations HIV AIDS Group Training First 100 records out of 235 displayed SBHG
26. e select client button Referral CHEAT ticidents Outreach Reports Pa Select Client The following screen appears Chents Webpage Dialog Last Name earch First Mame Middle Mame CE lias DOB Sot ID Other ID Medicaid Active Clients Please enter the search criteria Hinon enter the search criteria pEr Search This is how and where you re going to locate your client and their information SBHG EMR Training Phase Page 10 of 50 volume IV When conducting searches in Evolv CS you can type in full criteria such as an entire last name social security number etc Typing in just a few letters of the client s first or last name not case sensitive will pull up all clients on your team whose name begins with those letters However if you don t know the spelling of a client s name you can narrow down the search by using the percentage symbol typed in the last name or first name field Typing in just the percentage symbol will pull up all the clients on your team Typing in the percentage symbol and any letter will pull up any client s who have those letters in their name For additional information see Search Tips on page 31 of this Guide Clients Webpage Dialog Last Mame First Mame E Middle Mame AKAs Alias DOB st O Dt o Other ID Medicaid 0 Active Clients Dake of Medicaid ORO lies late Discharge Mone
27. er 9 Starbase 9 Track IT Windows WE Windows Marketplace 6 Windows Media E EMF Enhancement Change e EMR Enhancement f Cha 3 EMR Tips amp Tricks updated 1 7 08 What How Do Supervisor s have the ability to edit services Yes but they should not do so Editing services where the supervisor is net the original author will REMOVE the original author s signature which is a recoupment risk Can copy and paste from word into the EMR You will run into problerreferrors when trying to save which will cause you to loose data The EMR team will not be able to recover lost data Dio not cut and paste Where do I find required information from the first page of the select the Care Plan Progress Note template and complete the needed LA County DMH Care Plan Treatment Plan information Select this ternplate at intake and annual update of the Care Plan How dol Change a Diagnosis in the EMR Complete a Change of Diagnosis form obtain the appropriate signatures and turn it into the Center Coordinator In the EMR trigger the Change of Diagnosis service and document the reason for the Diagnosis changed EMR problems at home The EMR and IT tear can not help staf with home computer problerrs Refer to the Home User s Guide located in your EMR Binder What is the best way to contact the EMR team for support Use Track IT or send an e mail to helpdesk hen the EMR team responds to your track it s you will get an e mail no
28. eted case management 03 06 2008 04 00pm 01 07 10 MHS L Billing Authorization Case Consultation 01 01 2008 12 00pm 00 47 10 MHS Di amp Case Management D Service Managemen Service Entry S iC5 Admissian I To change the from or to date click in the field and manually change the date by month day and year The date needs to be entered numerically If you want to view services prior to the last 6 months you need to change the from so that it will encompass those dates of service Example if a service was provided on 11 17 2006 the from date must be on or before that date SBHG EMR Training Phase Page 15 of 50 volume IV You have the ability to filter the service entry screen by service type This is accomplished by clicking on the Service drop down menu and then selecting the service desired for review If you would like to view specific services click the Service drop down box and select the type of service You must click the refresh button Referral GHEE Incidents Outreach Reports Select Client addams Lurch DOB 01 01 1801 Age 207 Fal El ID 00002043 Intake 04 21 200 R Cemetery Lane Los Angeles CA 90021 CD 8 c E Client Information fay Service Management Personal Informatio Critical Information Relationshi
29. f the note the collateral present during the session complete a Collateral Information sheet attached and give it to your Center Coordinator SBHG EMR Training Phase Page 29 of 50 volume IV Now that the participants have been selected you need to select which objective was being addressed during the session The EMR allows you to select an objective from a drop down box instead of typing the information in the body of the progress note Mat e eld n a eel Preatmient Context MEAG Emine Treatment Areas 1 Atthe bottom of the service click the Treatment Context tab 2 Click the ellipses within the Treatment Context tab 3 Click the current objective goal on file you worked on during the session The result will look like this roan o helan Date a Date Mone ie goal MHS Client will decrease 4fHs and delusional beliefs Community CMHS 2fe7 2008 Step 3 From Sectweek to Leta ha iki i kd All of 4 records displayed T step 1 Impairments Barriers Confidentiality Statement Treatment Areas Participants Tasks Schedules 4 The result will look like this Impairments Barriers Confidentiality Statement Participants Treatment Context Tasks Schedul Treatment Areas F Goal MHS Client will increase meaningtul interactions with others from xweek to oxweek instead of withdrawing SBHG EMR Training Phase Page 30 of 50 volume IV You can select an objective link for t
30. fer to the Service Grid beginning on page 37 NOTE if a service is left in draft form not submitted to your supervisor for approval OR not electronically signed it will NOT be billed All Services must either be submitted and approved by your supervisor or electronically signed by you to be billed Leaving a service in draft form is the equivalent of having an un signed progress note in the client s chart which is a recoupment risk Creating skeleton services Saving a service where only the required fields are complete and leaving them in draft for the purpose of increasing your productivity is considered FRAUD If you create a service with the intention of returning at another time to finish the service keep in mind that per DMH policy ALL services are to be documented and signed submitted within 24 business hours of the date of the service Creating services and leaving them in draft is against DMH policy So let s review the icons that will appear next to the services entered 4 Select Client Addams Lurch DOR 0 01 1801 Age lh g IDA 0000204 Intake 04 21 2007 11 Cemetery Lane Los Angeles CA 30021 CD amp E Client Information Y Service Management Personal Information Critical Information E Relationships Service Entry SUCS Admission I YCE Admission I SUCS 6 month update SUCE Annual update E Health Information Q Aras Rass Wipro ONB TT Serie Sees Rr Billing Authorization E Case Management lt
31. g Phase Page 27 of 50 volume IV PROGRESS NOTE TEMPLATES If the client s collateral information and or Treatment Plan are already in the system it impacts your choice between IGBIRP BIRP IBIRP or GBIRP format IGBIRP You use the IGBIRP format when the collateral information and Treatment objectives are NOT entered into the EMR BIRP You use the BIRP format when the collateral information AND objectives in the Treatment Plan have been entered into the EMR NOTE To get collateral information entered into the EMR staff MUST submit Collateral Information form and submit it to the Center Coordinator at their site or the Wrap MH Intake Coordinator IBIRP You use IBIRP format if the collateral information is NOT in the EMR but the objectives are entered into the EMR GBIRP You use GBIRP format if the collateral information IS in the EMR but the objectives are not entered into the EMR The following services require a progress note e Crisis Intervention e Collateral e Family Therapy e Care Plan e Individual Therapy e Change of Diagnosis e Individual Rehabilitation e Dangerous Behavior Safety Plan e N C No Contact Note e Family Safety Crisis Plan e TBS Progress Note e Suicide Safety Plan e Targeted Case Management e TBS Monthly Review e Case Consultation You WILL NOT be able to submit the above services without a progress note For services not needing a progress note refer to the Service Grid located in the back of
32. g problems with saving submitting If you have any problems questions contact the QA Dept QA Dept assists supervisor and staff with trouble shooting problems saving submitting If you have any problems questions send a Track IT ticket to the EMR Dept EMR Dept will respond to ticket in Track IT Supervisor submits required paperwork to HR HR will notify the EMR Dept when required paperwork has been received EMR Dept will schedule a time to capture another signature with new title degree with staff Problem I am having problems with the EMR on my home computer I can t save a service or I lost forms in the EMR on my home computer or when I click the box will not open I can t see find my client in the EMR I am a supervisor and need more support in the EMR Staff Department Responsibility Responsible Center Coordinator Quality Assurance Medical Records Som lt Q lt P fom om A aD lt B Q Clinician refer to your Home User Guide the EMR team and IT team can not help with your home computer issues Clinician contact your Center Coordinator Supervisor contact your Supervisor Center Director a gt fom D gt TN SBHG EMR Training Phase Page 49 of 50 volume IV Note to Department Responsible Center Coordinator review Enrollment information and add staff either as Direct Worker or add workgroup to the client Center Director a
33. he following services Crisis Intervention Family Therapy Individual Therapy Individual Rehabilitation TBS Progress Note Targeted Case Management Case Consultation Collateral e N C No Contact Note NOTE If the Treatment Plan is NOT completed in the EMR you will NOT be able to select the objective goal within the Treatment Context If this is the case you will NEED to continue to type in the objective goal within the body of the progress note until the Treatment Plan is completed IF new behavior s occur during the session you will need to document them under the B behavior section in the body of the progress note Additionally you must indicate an objective goal will be developed to address the new behavior s IF Crisis Intervention is provided and there is no objective on file document the behavior s and intervention s in the body of the progress note Additionally you must indicate if an objective goal will be developed to address the behavior SAVING A SERVICE You are now ready to Save this service i E s Cancel g Print hle r haw Information la Counti aie Exempt From Billing Mo Show To save the this service click on the save button fsx When you save you will be brought back to the Service Entry Screen under the Client Module The saved service will now show in draft format in the Service Entry Screen You can modify this service at any time while in draft format by simply cli
34. horizati El Program Community MH Services From 12 01 2006 12 00am E Lase Management Service Due Date Scheduled Date Time Actual Date Time Duration Sta A fi g Enter New Service Schedule Service SETAC UCT Individual Rehabilitation 01 02 2003 09 30am 02 15 2 MHS sal ice Entry s z ca i El SVCS Admission I a NoContact fc Note 4 12 26 2008 02 00pm 01 00 2 MHS SCS Admission I a Individual Rehabilitation 12 01 2008 09 00am 02 20 3 MHS o E H ae Individual Rehabilitation 12 01 2008 09 00am 02 20 2 MHS m SWICS Annual update S C5 Discharge Individual Rehabilitation L2j01 2008 01 00am d2 20 2 MHS G Assessments Individual Rehabilitation X 11112008 09 30am 02 15 2 MHS A A Notes box will open where you can view the original note documented e Notes Webpage Dialog hle Close Mers Actions El Date Time 1270172008 09 00am Es Staff 3 MHS System Entry Date 12 05 2008 10 53am Approved Behavior Intervention Response SBHG EMR Training Phase Page 34 of 50 volume IV Click on the hlen button e Notes Webpage Dialog A ijlt Close 0 CC ba DateTime 12 01 2008 09 00am E g 5 Staff 3 MHS System Entry Date 1247 057 200 10 53am Approved Behavitc Intervention Hesponse Mew Actions e ADD Form Webpage Dialog Motes La Save wa Cancel g Print fle Close El Notes Information Date Time 02 08 2009 Time 08 33 PM Staff Staff Duration
35. ing Phase Page 8 of 50 volume IV Notice the Referral name in the Parent Selection Bar Program Family i p Referrals Client Incidents Vutreack Reterral Cases ETI New Select Referral Tucker Heater DOB 05 04 2000 Agency Referral Referral Information Relationships Health Information E Testing Screening Pre Client Documentation Agency Referral Referral Information Relationships Under Agency Referral click the Health Information amp TestingScreening sign next to Testing screening Pre Client Documentation Domains Problems Meeds Strengths Materials Received Contacts Billing Authorization Referrals Made To Programs To External Sources Program Enrollments Agency Referral Referral Information Relationships Health Information Testing Screening Pre Clienk Documentation Click on Pre Client Documentation Domains Problems Weeds Strengths Materials Received Contacts Billing Authorization Referrals Made To Programs To External Sources Program Enrollments Follow instructions on page 16 on how to fill out a service NOTE Documenting NON Billable services on a Referral should be done ONLY if the Referral is NOT an active client If the Referral IS an active client review the next section on how to find and complete a service on a client SBHG EMR Training Phase Page 9 of 50 volume IV PART II OPENING A CLIENT RECORD First click th
36. me 7 End Date Time oak service u ntil a bolded fields have i t Faceto ie Time b een fi e d n ihh mm Other Time hh mm Total Time hh mm Number of Family Collaterals Number of Non Family Collaterals Evidence Based Practice Boyd Angela Completed By Submit To Service Site E Diagnosis Current Diagnosis GAF Score DSMIy Priority Priority Description Mood Disorder NOS History of ADHD Combined Type 314 01 314 01 None Reported 0 0 Educational problems Problems with primary support group 40 40 a ial Frimary Secondary Program Providing CMHS Service Facility Providing Service Awice Authorization O Progres Progress Mote Paragraph Font Sie v EG BE Bs Ube Impairments Barriers Confidentiality Statement Participants Treatment Context Impairments Barriers Currently on File Problem Statement Externalizing Disorders Conduct Persistent refusal to comply with rules or expectations in the home school or community Excessive Fighting Intimidation of others Cruelty Disorder or violence Stealing School adjustment problems Repeated conflict with authority Figures SBHG EMR Training Phase Page 18 of 50 volume IV A Closer Look User Help File is an EPSDT service glossary that includes definitions and key elements of the various types of services used for writing progress notes 2 ADD Form We
37. mn that indicates participants were selected from drop down box within the service Materials were used during service not common If a green check mark is under this column it indicates materials were used during the service Electronic Signature was applied by original author of the service When there is a green check mark under this column that indicates the electronic signature of the Original author was applied to this service SBHG EMR Training Phase Page 33 of 50 volume IV ADDING AN ADDENDUM TO A PROGRESS NOTE If for whatever reason you or your supervisor feels the progress note needs additional information in the body of the note instead of your supervisor un approving un approving the note back to you you are able to add an addendum to the body of the note while the Progress Note is in Submitted or Approved status If the Progress Note is in draft you are able to edit the content of the Progress Note from within the Service To add an addendum click on the al progress note icon to the far right of the service Incidents Outreach Groups Referral Finance Agency Reports Setup Program Mifient Family Attendance Resource oB cca F B Tracka Families Referrals E Client Information aie Service Management Personal Informatio Critical Information Relationships 5h issi SCS 6 month A Health Information Authorization Reque Nevice Refresh Service Authorizatio Billing Authorization l Payment Aut
38. n be accessed through this module e Client Personal Information e Treatment History e Worker Assignments e Enrollment Information e Document Billable and Non Billable Services e Complete Forms NOTE notice that under the Referral Module it states Select Referral vs under the Client Module it states Select Client SBHG EMR Training Phase Page 7 of 50 volume IV DOCUMENTING NON BILLABLE SERVICES ON A REFERRAL To document a NON BILLABLE N C note on a Referral someone who is NOT a client click on the Referral Module Program A Family Referral Referrals CHEM Cases Incidents Mew Select Referral Click Select Referral A Search box will open Type in the name of the Referral Referrals To Agency Webpag Dialog x Last Name tucker First Mame AKA Olias Soh Referral Source Referral ID Office Responsible Priority Has Client Record Click Search The name of the Referral will show on the bottom of the search box Referrals To Agency Webpage Dialog Last Name tucker dad First Mame AEA alias SSM Referral Source Referral ID Office Responsible Priority Has Client Record Name AKAlAlias Date of Birth Referral Source Date of Referral Office Responsible Has Client Record 4 1 2008 Mone Oasis lon Wait List Tucker H lsiaieoo0 CAMBODIAN ASSOCIATION Click on the Name of the Referral SBHG EMR Train
39. orm and turn it into the Center TM Intake Coordinator They will then need to complete the billing information in the EMR by selecting Change of Diagnosis in the Service Entry Screen El Diagnosis Current Diagnosis Date Priority Description Diagnosis 4 25 2008 Primary Dysthymic Disorder 300 4 300 4 1 4 25 2008 z Secondary Specific Phobia 300 29 300 29 2 4 25 2008 J Other No Diagnosis on Axis II W109 WF1 09 3 4 25 2008 None Reported 0 0 4 4 25 2008 Problems with primary support group 5 412512008 42 42 Impairments Barriers can be found beneath the Progress Note section in the Service Entry form Impairments Barriers Confidentiality Statement Participants Treatment Context Impairments Barriers Currently on File Date Identified 4 25 2008 Category Problern Statement Internalizing Disorders Anxiety Client acts anxious in Client avoids tasks that require performing in Front of others such as oral reports or class participation and her important social anxiety oF such tasks is negatively impacting her grades due to not turning in assignments or participating in class activities discussions Appetite Energy Sleep Disruption Internalizing Disorders Dysthymic Client reports having insomnia and a reduce appetite Cx reported Falling asleep in class Internalizing Depressed Mood Client reports Feelings of sadness during the day which interfe
40. ory button A box containing the History of the specific service will open F EDIT Form Webpage Dialog SYCS Simple Service Entr Client Addams Lurch DOB 01 01 1801 ID 00002043 Intake 04 21 2007 12 00pm Poe eo cance E Print send alert O histor Submit jle close lt lt lt 2 Update History Webpage Dialog is Created By ho MHS Mental Health Specialist IT on 06 24 2008 04 24pm PT Created By ho MHS Mental Health Specialist II on 06 24 2008 04 24pm PT SBHG EMR Training Phase Page 38 of 50 volume IV SYSTEM TIME OUT SAVING DATA A SYSTEM TIME OUT occurs when the system automatically logs a user off because of inactivity or an unexpected disconnection from database If you leave the EMR open without saving for more than 30 minutes the server will log you out of the EMR You will be see the following message when you return prompting you to login again Your session has timed out Login Again Zan f this occurs you will loose any UNSAVED data Neither the EMR nor the IT Team will be able tor recover lost data that was not saved Saving your services periodically will help prevent the loss of services data The EMR team recommends saving services every 10 mins particularly when you are working on Assessments and the Treatment Plan To save a service you will have to complete all required fields first and then click Save SYSTEM LOG OUT When you are ready to en
41. our Scanning packets who do I give the packets to and when are they due Forgot my password for the EMR or having a problem signing into the EMR Staff Responsibility Supervisor Clinician contact your supervisor the QA Dept the Center Coordinator or Medical Records Dept Clinician send a Track IT ticket to the EMR Dept Department Responsible Center Coordinator Quality Assurance Medical Records Center Director SBHG EMR Training Phase Page 47 of 50 volume IV Note to Department Responsible Supervisor follow the Deletion Policy and or your Supervisor Handbook request deletion from the Finance Dept NOTE there is a difference between deleting a Claim billing information for a service and a service documentation of the service provided IMPORTANT Supervisors DO NOT un approve services that have already been billed green check mark under column if you need to do something with a billed service contact the Finance Dept before un approving Finance Dept will delete the service AND OR Claim as requested Supervisor review the packet process with your staff if you have any questions problems contact the QA Dept the Center Coordinator or MR Dept QA Dept Center Coordinator or MR Dept review the packet process with supervisors as needed EMR team will change your password and notify you of the change in Track IT staff is responsible for checking
42. ps Service Entry S CS Admission I S CS 6 month update S CS Annual up abe Health Information Physical Characteristics Refresh Diagnoses Information IP Treatment History E Program Community MH Services From 04 21 2007 12 00pm Substance Use S iC5 Discharge a Bleraies Service Due Date Scheduled Date Time Actual Date Time Duration Staff Zi zt M a Medications Targeted case management 03 06 2008 04 00pm 01 07 10 MHS DI Billing Authorization Case Consultation E 01 01 2008 12 00pm OO 47 10 MHS Case Management E Service Managemen Service Entry 06 13 2007 12 08pm 01 18 10 MH No Contact NC Mote 505 9 07 Individual Therapy 0421 2007 03 45pm 01 39 10 MHS SVC5 Admission I CAFAS Results Case Consultation Collateral Contact Crisis Intervention Documentation Family Collateral Indpendent iwing skills scall IL55 No Show Canceled Plan Development Reschedule Safety plan School Consultation For IEF Targeted case management TBS Referral Screening To show all services again you must select All Services from the service filter and click refresh Case Consultation Collateral Contact Crisis Intervention Documentation Family Collateral Individual Rehabilitation Indpendent living skills scall IL55 Mo Show f Canceled Plan Development Reschedule
43. r with her attention and concentration at school of S 2008 Disorders Client reports sadness and worry regarding mother s health issues Cancer Mother reported that client often Dysthymic appears sad after speaking with Father due to him breaking promises and not having direct involyment in cx s life Internalizing Irritable Mood with Client reports that her irritability began about a year ago and has increased progressively since Client reports 55 2006 Disorders duration of atleast 1 angry outborts and bickering towards Family members at home Client is defiant at home and argumentiwe with Drysthy mic vear adults especially her aunt and mother Client disobeys house rules SBHG EMR Training Phase Page 25 of 50 volume IV Continued look at the required fields Program Providing ry Service Facility Providing Service Community MH Services Service Authorization Program Providing Service Should auto populate to Community MH Services CMHS If it does not auto populate 1 click the Program Providing Service button Program Providing Service a drop down list will open select Community MH Services from the drop down list Facility Providing Service You must select the Facility where the service was provided If the service was provided out in the field then select the facility you are assigned 1 click on the Facility Providing Service button Facility Providing Service a drop down menu
44. sment No Yes No 29 TBS Monthly Review Yes Yes No 30 Trauma Screening es Z O lt O 31 Treatment Team Note No Yes No SBHG EMR Training Phase Page 42 of 50 volume IV Supervisor PN review Objective Link Services Needed b oma W Treatment Context 32 Case Consultation Progress Note Yes Yes Yes 33 Collateral Progress Note Yes Yes Yes 34 Crisis Intervention Progress Note Y es Yes Yes 5 26 37 n i SBHG EMR Training Phase Page 43 of 50 volume IV Who do contact if have EMR problems Review the EMR Decision Tree below The Department Responsible columns should be read from left to right as far as who to contact first when a problem arises If you still need to contact the EMR Department notify your supervisor first then submit a Track IT ticket NOTE Be descriptive of your problem in the Track IT ticket and include details such as name of the client date of service name of the service number of minutes billed etc The more information we receive when the problem is first reported the quicker our ability to problem solve EMR Decision Tree Note to Department Responsible Problem Staff Department Responsibility Responsible Center Coordinator Quality Assurance Medical Records Center Director Center Coordinators enter Collateral Information in the EMR Collateral not in the Clinician complete a EMR Collateral Information Sheet and give it to
45. ssist Supervisors with navigation questions if you have any questions problems contact the QA Dept QA Dept assist supervisors with navigation questions if you have any questions problems send a Track IT ticket to the EMR Dept EMR Dept will respond to ticket in Track IT Problem I noticed an error in one of the documents scanned in the EMR I need Initial EMR Training Staff Department Responsibility Responsible Center Coordinator Quality Assurance Center Director Medical Records Supervisor Clinician contact your supervisor z 5 z z S a Clinician show up ON TIME for scheduled initial EMR training S p z a SBHG EMR Training Phase Page 50 of 50 volume IV Note to Department Responsible Supervisor contact the Center Coordinator or Medical Records Department Center Coordinator or Medical Records Dept follow the process outlined for deleting a scanned packet NOTE the Center Coordinators and Medical Records Dept should be auditing the packets PRIOR to scanning this will help reduce the number of errors and the need for deleting packets EMR Team Training Dept provide Initial EMR training
46. st the type of service is auto populated Activity Type and Encounter With are not required fields do not enter any data Client Involved indicates client s involvement in the service The system checks this field by default You must un check this field if client is not involved in the service SBHG EMR Training Phase Page 20 of 50 volume IV A closer look at the required fields Completed Information Actual Date Time End Date Time System Generated Face to Face Tine hhmm Other Time hh mm Total Time him Number of Family Collaterals Number of Non Family Collaterals Evidence Based Practice Completed By oyd Argel Submit To Service Site UECOE Time Actual Date Time is the date and time you provided the service Date can entered numerically either by hand can use or or by clicking on the calendar Time is actual time service started Time is entered numerically i e 1 42 pm or 9 34 am NOTE the EMR will not allow a future Date OR Time to be entered End Date Time is automatically generated by the system when you save the service NOTE the End Date Time field is automatic and will not allow you to enter any information Face to Face Time In order to claim Face to Face time the client MUST be present NOTE Enter time in minutes The system automatically changes it to hours and minutes ex 63 minutes would appear as 1 03 SBHG EMR
47. t Start New Plan gt if there is a Treatment Plan you will see either CMHS Initial or CMHS Review 4 This indicates that there is at least one objective on file Determining if there is Collateral Information 1 On the navigation bar under Client Information click on Relationships 2 Click on Collaterals 3 If there is not Collateral Information you will see No Information Found if there is Collateral Information you will see a list of Collateral name s 4 Verify the Collateral you will be referencing in your progress note is listed Knowing if this information is on file will impact which format you will use when writing a progress note SBHG EMR Training Phase Page 12 of 50 volume IV After completing this section you will be able to 1 Navigate through the Client Module 2 Understand the navigation bar 3 Enter a simple service on a client Now that you have selected your client you are to ready enter a service All services provided for any client are housed under the Client Module and are located within Service Management in the Navigation Bar The service entry is the equivalent of the progress note section of a chart Referral CHEAT Incidents Select Client Addams Lurch Client Information Personal Information Critical Information Relationships Health Information Billing Authorization Under Case Management E click the sign next to E E a 5 Plan Development Se rvice Management Health Inform
48. tached to this service upon submission to your supervisor Click this button to apply your Electronic Signature for those services that do not require supervisor approval Refer to the Service Grid for a list of services The envelope with an arrow indicates the service has been submitted to your supervisor for approval Once the service has been submitted it is no longer modifiable If you need to edit the service and or note for any reason you will need to contact your supervisor and ask them to un submit the service You will then be able to make the desired changes and then re submit back to your supervisor This icon will take the place of the Electronic Signature icon Explain to the participants that this symbol does not impact them Indicates the services has been approved by your supervisor Explain to the participants that the symbol of an envelope with a red line does not impact them Indicates a progress note has been written in this service Indicates a progress note has NOT been written for this service For services that require a progress note you will not be able to submit them when this icon is showing This icon indicates that your Electronic Signature has been applied Service has pulled into a batch If there is a green check mark under this column the service has been pulled into a batch and has been or is ready to be billed Participants were involved in service If there is a green check mark under this colu
49. tercare Plan Suicide Assessment PECFAS Ci Trauma Screening 4 Treatment Team SBHG EMR Training Phase Page 14 of 50 volume IV Details of the service entry screen Start with From and To dates which act like a filter only showing services provided during the time period specified The list of services provided for the client within the previous six months will show To find a service older than six months change the from and to dates to list more services Then click the refresh button 7 pn E TEN A E Referral Client Incidents Outreach Reports E 1 l 4 ES Ue amp Select Client addams Lurch DOB 01 01 1801 Age 207 Bal B 1D 00002043 Intake 04 21 eens Lane Los Angeles CA 90021 cD 8 FN Client Information fe Service Management Help Personal Informatio My Progress Motes Critical Information SYS Discharge Referrals Scanned Documents Relationships Service Entry SYS Admission I SYCS Arimiccinn T SCS 6 month update SYCS Annual update amp Health Information Physical Characteristics Sertice All Services ea Refresh Diagnoses Information a Treatment History E Program Community MH Services From 04 21 2007 17 Enter New Service Schedule Substance Use cece Service Due Date Scheduled Date Time Actual Date Time Duration Staff sau 3 Medications Targ
50. the care plan AND Inked to the chents Mental Health Condition Diagnosis Impairments documented in the Targeted Case Management EPSDT Manual page 40 LINKAGE PLAN DEVELOPMENT MONITORING CLIENTS PROGRESS Services that assist the chent to access needed medical social rehabilitative prevocational vocational or other community services MUST include ONE or MORE of the following elements communication coordmation and referral moritering sence delyery to ensure chent s access to senace and the service delivery system e placement services J Local intranet A 100 SBHG EMR Training Phase Page 19 of 50 volume IV Details of the Service Entry form H No Show Information Exempt trom Eiling No Show Hl Encounter Information Entered With Agency Placement 11 16 2004 100pm Type Individual Rehabilitation Activity Type Encounter with Clent Invoked vi County ID all clients receiving Mental Health Services are given an identification number by the County This field is pre populated and you cannot enter or change the number Exempt from Billing and No Show DO NOT click in either box unless instructed by your supervisor and or the Finance Department BEWARE if either box is checked the service will not be billed Entered With identifies the First Date of Service FDOS Pre populated and cannot be modified Type based on your service selection from the drop down li
51. this manual Starting on page 37 SBHG EMR Training Phase Page 28 of 50 volume IV Now that you are done with the body of your note you MUST identify who was present during the session If you indicate there was Family and or Non Family Collateral Present during the session you MUST identify who they are The EMR allows you to select collateral information from a drop down box instead of typing the information in the body of the progress note The Participants Section is the place where the Relatives Collaterals are identified and selected Impairments Barriers Confidentiality Statement Test Link Treatment Context Tasks Schedules Relatives Collaterals Participating Organizations When selecting a participant s collateral s utilize the following steps 1 At the bottom of the service click the Participants tab 2 Click the ellipses under Participants Role and select the description 3 Click the ellipses under Participant and select the name of the participant Cc gt Tasks Schedules Relatives Collaterals Collateral Description Relationship Type Huey Kimberly Mother Collateral Foster Home Member VERY IMPORTANT in order to select a collateral from within the Participants dropdown box the collaterals MUST first be entered into the EMR Contact your Center Coordinator to have the collaterals entered into the EMR IF the collateral information is not entered into the EMR yet document in the body o
52. tifying you of our response Be sure te check your e mail for an e mail notification indicating the EMR team has responded to your ticket Ifwe need more information from you you will need to log back inte Track It and can respond to our request How dol know what is an EMR problem or OA Operations The EMR team is developing a Decision Tree that will help staff problem identify the correct person department to problem solve the issue This Decision Tree will be done in the next couple of months The QA Department will also be adding a column on the QA report that will indicate who is responsible for fixing the problemi SBHG EMR Training Phase Page 4 of 50 volume IV LOGGING INTO THE EMR For the purposes of this training click on the Training Environment on the EMR portal page the login page will open Your training material has your logon name and password to enter into the logon screen for the training EMR Enter your login name and password Mot case sensitive Login Name mhs Password oer TRAINING SITE Copyright 1999 2004 Defran Systems Inc All Rights Reserved This software contains confidential and proprietary information developed by Defran Systems Inc and is protected by copyright and trademark law Unauthorized reproduction or distribution of this software is prohibited Login Name mhs Password password Click SBHG EMR Training Phase Page 5 of 50 volume IV When you
53. try SCrGieiiimmmmmmmrctnvnrntnty cccccccccsccssscscresesece senile nana 15 ooo From and To da eer lle 15 59 UAE ll Ee lll eee 16 eons NEW SEPvICe fhh MMMMMMOIEMEIE 000 sscseecerecsconsesesecon e E 17 A closer look at the Service Enty FOM aa hssesseeseeseseeso noo eaire neenneneereeresonrersssssssssssses 19 nEs Note Templates ae russ avusgesenvalWauyrs ccecccseuseuenas 28 Entering Collateral Participants present sseessssesssessesesssesessrsssrsessetesessessrsessrensesesesressse 29 Selecting Objectives Addressed Treatment Context cccccscccssccecssssecssssessssssscssssseeeees 30 GRE Ly E 31 Submitting a Service vs Electronically Signing a SErViC cece ceccceseesessesessessesseeeeeees 32 CORSIE TCON ee nooo a an onene noenee reses 33 aging an ACCGENCUM cccccccccscrerecrecererecre so gf MMMM sseuseusesesessesansavscnscenecnasansansersene 34 History Button Pe See R 1 System Time Out Sane Data Se E 39 BE Log OUt sessssseessssnsee e songs 1 oc sccsscccccccseesenssecscsescescvnscsssspenacessecaaseseees 39 oo 0 ee _ 40 ea ses ac ccneuscuscuossssnennsvenenseucustsnsueavavecueserenstsnseassaeas 42 Se et eI a 44 SBHG EMR Training Phase Page 2 of 50 volume IV PART EVOLV SYSTEM CONVENTIONS After completing this section you will be able to Login to the System Understand the Browser Interface Identify Components of the Evolv CS
54. umentation click p Save e ADD Form Webpage Dialog EF pans Charles DOB 04 05 1983 dh Cancel g Print nformation Date Time 02 08 2009 H amp A Time 08 33 PM Staff Boyd Angela Staff Duration System Entry Date Mote E O OE The Progress Note will close and you will be brought back to the Notes box The addendum Progress Note will show under the original Progress Note Notice the Main Note column The original note is the main note and the addendum is not the main note e Notes Webpage Dialog New Actions BEI Date Time Staff Duration System Entry Date H 4 12 01 2008 09 00am 3 MHS 12 05 2008 10 53am jogjos 2009 08 33pm Boyd Angela 00 45 N yoz 08 2009 11 15pm Click fil close and you will be returned to the Service Entry Screen SBHG EMR Training Phase Page 37 of 50 volume IV HISTORY BUTTON Everything you do in the EMR leaves an electronic trail foot print State and County Auditors will use this trail in their audits to determine when and who provided what services and when those services were documented Be careful with the number of times you are in and out of a service Each time you go into a service you leave a foot print Here are the steps for viewing the history within each of the services 1 2 3 4 Click into a service The Simple Service Entry Screen will open Click on the Hist

Phase I User Manual - Welcome to the Stars Behavioral Group

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