Interim Inc.-Specific
Documentation
Contents
Bridge House Day Treatment ... 2
Bridge House Residential ... 3
Interim Manzanita House ... 4
To write a needs appraisal ... 4
For the weekly summary towards the needs appraisal: ... 5
To Complete the “Resident’s Status Report to Psychiatrist” ... 6
For the Discharge Plan: ... 6
Co-Signatures ... 7
Crystal Reports ... 7
Waitlist and Referrals ... 8
Other functions ... 10
Please refer to the Monterey County Behavioral Health Electronic Medical Record-AVATAR-
{EMR User Guide} for full details on how to complete forms in AVATAR.
Interim-Specific Documentation Standards*
Bridge House Day Treatment
1. Progress notes will be entered for clients in the program called Interim Bridge Day Treatment (63ASOCDT). Progress notes are entered using the service code “ 359 Day Treatment Group Non-Billable” using the Progress notes (Group and Individual) form in Avatar
a. Enter the number of minutes (duration) for the group.
b. Service should be tied to the treatment plan.
c. In the body of the progress note, indicate the start and end time for the client’s participation in the group.
Part 1 or 2
2. Individual Progress notes will be entered using service code “389 Daily Progress Note Non-Billable” in the Clinical Progress Note MC form in Avatar. You may use this option to document staff’s collaboration with family or other staff.
a. Enter the number of minutes (duration) for the service.
b. Service should be tied to the treatment plan.
c. Once you have entered the information on the progress note click “final.”
Bridge House Residential
1. Service should be documented in the program called Interim Bridge Residential (63ASOCRES) 2. Individual Progress notes will be entered using Clinical Progress Note MC form in Avatar.
3. Weekly Progress Notes should be entered with service code “399 Weekly Progress Note”
a. A duration of “0” minutes should be entered.
b. Service should be tied to the treatment plan.
Interim Manzanita House
1. Services should be documented in the program called Interim Manzanita House (27ASOCMZ) 2. Progress notes will be entered using Clinical Progress Note MC form in Avatar.
3. Shift notes can be documented with the following service codes:
a. “100 AM Shift Note Non Billable”
b. “101 PM shift Note Non –Billable”
c. A duration of “0” minutes should be entered for all shift notes
d. Once you have entered the information on the progress note click “final.”
4. Progress notes will be entered using Clinical Progress Note MC form in Avatar.
5. Weekly Progress Notes should be entered with service code “399 Weekly Progress Note”
a. A duration of “0” minutes should be entered.
b. Once you have entered the information on the progress note click “final.”
To write a needs appraisal
1. Individual Progress notes will be entered using Clinical Progress Note MC form in Avatar. 2. Enter the information in a progress note
3. Progress Notes should be entered with Service Code 103
5. Right click and insert the template called “Appraisal Needs Services Plan “ 6. Appraisal Needs Services Plan right click template will consist of:
a. Assessment Date:
b. Reassessment Date:
c. Resident’s medical history:
d. emotional, behavioral and physical problems
e. functional limitations
f. physical and mental; functional capabilities
g. ability to handle personal cash resources and perform simple homemaking tasks
h. client’s/resident’s likes and dislikes
7. Fill in each section of the needs
8. Have the client sign the needs assessment before you finalize the note. If the client is not with you, save the note as a draft
9. After the needs are established; go into the treatment plan
10. Update the treatment plan with the needs identified in the needs appraisal.
For the weekly summary towards the needs appraisal:
1. Copy the most recent 103 Needs Appraisal note (we suggest you do this from the widget)
2. Past the assessment in the new progress note – use the service code “399- Weekly Progress note”
To Complete the “Resident’s Status Report to Psychiatrist”
1. Use Clinical Progress Note MC form in Avatar to complete a progress note 2. Use “389 Daily Progress Note Non-Billable”
3. Send the note pending approval to the psychiatrist
4. Right click and use the template “Resident’s status report” this template includes a. Delusional:
b. Hyperactive:
c. Hyperverbal/Pressured Speech: d. Using Medications as Prescribed: e. Appetite/Eating Problems: f. Substance Use:
g. Sleep Disturbance: h. Aggressive Behaviors: i. Physical Health Problems: j. Depressed:
k. Self-harm behaviors:
l. Other Psychiatric Symptoms or Issues:
For the Discharge Plan:
1. Progress notes will be entered using Clinical Progress Note MC form in Avatar 2. Use service code xx
3. Use the right click template “Discharge Plan” which consists of:
Co-Signatures
For Progress Notes that require a co-signature, be sure to select the “co-signature required” in the Note Type option.
1. Select the Co-Signature Required option
2. Selecting this option will send a “to do” message to the co-signing staff’s To Do widget for review.
3. Once you have entered the information on the progress note click “final.”
Crystal Reports
Waitlist and Referrals
This form should be used to receive referrals for entry to your program. Please refer to Chapter 20 of the EMR Guide for details on how to use this form.
Bridge House Day Treatment Bridge House Residential Manzanita House
359 Day Treatment Group 399 Weekly Progress Note 100 AM Shift Note 389 Daily Progress Note 103 Needs Appraisal Note 101 PM Shift Note
399 Weekly Progress Note 399 Weekly Progress Note
103 Needs Appraisal
Please refer to the Monterey County Behavioral Health Electronic Medical Record-AVATAR-
{EMR User Guide} for full details on how to complete forms in AVATAR.
Other functions
Function Avatar task Rules
DC Summary Progress Note Rule: Signed by Client, staff,
No Harm contract Scan into “Interim folder” in avatar signed by client and staff
Safety Plan Scan to “Safety Plan folder” Handwritten and signed by client
Assessment Interview form
On paper *Once we are live on Avatar
we will be more familiar with what info is available to us and can look at not keeping duplicate info. I can then look into making changes to our form, but we will need some time to do this.
Interim agreements, policy, room searches etc. consent for rehab, consent for emergency medical services, consent for photograph, personal rights form
Will be scanned into appropriate interim folder.
Signed by client and staff
Interim within consent form
Scan this into the folder Signed by client and staff
TB Test Scan in Interim folder
Healthcare plan Stays on paper, but scan in at discharge into the interim folder
Medication Record Stays on paper, but scan in at discharge
Status report Will be a template in the progress note, if the MD needs to know this, send the note “Pending approval” to the MD.
Program fee agreement
Scan into interim folder Signed by client and staff
Sign out sheet Scan at discharge, into the interim folder
Completed by clients and signed by staff
Discharge Plan for client
Send discharge plan template to Amie – this will be a progress note template in avatar