wits training: treatment plan, consent and referral

WITS Training:Treatment Plan,

Consent and Referral

Topics Page

Treatment Team Group 2

Treatment Plan 3

Treatment Plan Review 13

Medications 18

Consent 20

Referral 22

Linked Consent 26

Table of Contents

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3

Treatment

Treatment Team Groups can be created at the Agency level.

The Tx Team Groups menu is available under Agency.

1.Click on Add New Treatment Team Group Record to create group.

2.Click on Add Staff to Group link in order to add staff to that group.

3.Select a Staff, his/her Role in the team, and click on Save.

4.Add as many staff members as necessary. When you are done, click on Finish. You will then see the list of all the treatment team staff for that group.

Note that this step is not mandatory. This feature allow you to setup the known groups in your agency and will make the client assignment faster and easier. Individual staff can be added to a client treatment team at the Treatment Plan level.

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Treatment Team Groups

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Treatment


1. Getting here: Click on the main menu item Treatment which expands to multiple menu items, one of which is Treatment Plan.

2. Treatment Plan List: This screen lists all treatment plans for the active case. There can be only one active treatment plan at a time.

3. If no treatment plan exists, click on Add New Treatment Plan Record to create a new treatment plan. This will take you to the Treatment Plan Profile Screen. An existing Treatment Plan can be reviewed by clicking the Review hyperlink in the Actions column of the Treatment Plan List.

Note: Once a treatment plan is completed and signed by the treatment team it cannot be changed in its original version. Any modifications can be made by creating a new version of the treatment plan. A new version creates a copy of the original plan only with a new version number. This new version can be modified until it is signed by the treatment team. A Treatment Plan Review can also be conducted to review and update the Treatment Plan. This also will create a new version of the Treatment Plan.

Treatment Plan

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Treatment1. Treatment Plan Profile: This screen

provides the basic information about the plan. The shaded area is read only information which is either carried forward from earlier modules or is created by the system. The Next Review Date defaults to 120 days from today.

2. Plan name: This is the name by which a plan is commonly known within an agency.

3. Plan Status: When the status of the plan is Active – Signed Off or Inactive, it will not allow any updates. Updates can be made only to plans that are in ‘Active – Not Signed Off’ status.

4. Create New Version link allows you to create a new version, which is a copy of the current plan so that you can modify it. You can use this only when you have a current active signed off plan or an inactive plan and need to make modifications to it.

5. If you click on the Create New Version link, it will bring up a confirmation screen asking you if you really want to create a new treatment plan. Click Yes if you want to make the current plan inactive and create a new version.

6. You may click the “Print report” button to print a treatment plan, from this screen.


Treatment Plan Profile

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6.Sign Off link: When you click on this link it changes the status of the plan from ‘Active Not Signed Off’ to ‘Active Signed Off’ and you can no longer make any modifications to the plan.

7.Until the plan is signed off, you can add additional treatment team members (or change their review status) by clicking on the “Add Team Member” link.

8.A confirmation screen comes up asking if you really want to sign off on the plan. It also reminds you that you should get signatures of the treatment team members on the paper version of the plan.

9.Click Yes and it will bring you back to the plan with the status changed to ‘Active Signed Off’.

10.The Treatment Team section comes pre-populated from the information at admission.

11.Create an Inactive Draft allows you to create a draft of the plan, without inactivating the current plan.


Treatment Plan Profile

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Treatment

The Treatment Team can be assigned to that client from the Treatment Plan Profile screen. Click on Add Team Member in order to edit the Treatment Team for the client.

1. Click on Assign Group link in order to add an a treatment group staff to that client’s treatment’s team.

2. Click on Add Team Member link in order to add an individual staff to that client’s treatment team.

3. Select a Staff, his/her Role in the team. Then mention if this team member is a Review Member.

4. Set the Deny Access to Client Records flag to Yes if you don’t want that staff to see that client record at all. The client will not be available on the Client List screen for that user.

5. Click on Finish and add other Team Members as necessary

You do not need to add the client to a treatment team. However, if you require Review Members at the Treatment Review level you need to make sure they are all setup here.


Treatment Team

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Treatment

1. This screen allows you to document

additional background information for the client’s treatment plan.

2. Presenting Problems: This is pre-populated based on Presenting Problems documented at Intake.

3. All the other fields are free text boxes which allow you to type unlimited information.


Treatment Plan - Overview

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Treatment

1. On the Client Diagnosis screen you will enter Primary Diagnosis and you may enter Secondary and Tertiary .

2. To enter Axis I, II, II ,IV and V click on the ‘Edit Axis Evaluation’ link at the bottom of the screen.

3. Select a Diagnosis, if it is the Principal Diagnosis or not, and click on Add to Axis to add that diagnosis to the selected Axis.


Treatment Plan - Diagnosis

Note that only users with Client Diagnosis role will be able to edit that screen.

10

Treatment


1. This is the first screen in a series of screens to document Problems, Goals, objectives and interventions.

2. Click on Add New Treatment Plan Problem Record to add a new problem and goal.

3. All the problems written in the treatment plan are listed here.

4. Click on Review if you want to review the details or revise the problem.

5. It is also helpful to add problems, goal and objectives from the plan outline screen.

Treatment Plan – Problem

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Treatment

Goals and Objectives

1. The top part of each screen is shaded and read-only. Each screen will contain information that was entered in the earlier parts of the treatment plan.

2. Enter information about Goals that are associated with the Problem prior to moving forward.

3. For each Goal, multiple Objectives may be entered.


Treatment Plan

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Treatment


1.Each planned service needs to be documented individually.

2.To document a planned service, click on Add New Planned Services Record which will take you to the next screen.

3.Select the appropriate options from the various drop-down boxes.

4.Objectives from the treatment plan may be associated with the planned service . All the objectives written in the treatment plan will be listed here. To select the relevant objectives, click on Add Objectives.

5.Check the boxes next to the objectives that should be associated with the Planned Service. Click Finish.

Treatment Plan – Planned Services

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Treatment


1. This screen provides an

outline view of the Tx Plan. You can make changes to the various items of the treatment plan by clicking on the hyperlinks next to the item.

2. For example to add an objective click the Add Objective hyperlink next to the appropriate Goal. This will take you to the Objective screen in the Tx plan. Once you have added the objective information click Finish and you will be returned to the Plan Outline screen. The new objective will appear on the outline screen as well as in the TX Plan Goal screen.

3. Click on Finish when you are done reviewing or adding to the Tx Plan using the outline screen.

Treatment Plan – Outline

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Treatment


1. Getting here: Click on the main menu item Treatment which expands to multiple menu items, one of which is Tx Review

2. Treatment Review List: This screen lists all treatment reviews for the active case.

3. To enter a new review click on Add New Treatment Review Record.

4. Any previously entered Treatment Reviews can be reviewed by clicking the Review hyperlink in the Actions column of the Treatment Review List.

5. You can also start a new Treatment Review by clicking the Perform Review hyperlink on the Treatment Plan Profile screen of the Active and Signed off treatment plan.

Treatment Review

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Treatment 6. Identifying Info: The review Period dates

will automatically populate for you. The date of review pre-populates with today’s date.

7. Updated Info: Enter the names of any documents that were reviewed as part of this review.

8. Assessments Conducted During This Review Period: Enter the names of any assessments given during the review period.

9. Click Next.

10. On the following screen, select the response from the drop down for the questions highlighted in yellow. Enter text in the text boxes for the other items. Any information entered on the previous Treatment Plan for Strengths/Resources will be pulled forward by the system to this screen. It can be changed as needed.

11. Click Next.


Treatment Review

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Treatment

12.Available Treatment Team Members: This list will display all members of a client’s treatment team that are indicated as review members.

13.To add a member of the team to this Treatment Review Team check the box next to the team member’s name and click the Add to Review Team hyperlink.

14.The selected team members will appear in the Treatment Review Team list at the bottom of the screen.

15.To remove a Team Member click the Delete hyperlink under Actions. This will not remove the team member from the Treatment Team only from this Review Team.

16.To indicate that the team member has signed off on the current treatment review click the Sign-off hyperlink under Sign-off.

17.Each team member must sign off using their own login. Alternatively, the Clinical Supervisor may sign off for team members.

18.Click Save to save this information and then click Next.

Page 3


Treatment Review

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Treatment 1. This screen shows the active

signed off Treatment Plan in an outline format and allows changes to be made.

2. To make modifications to the Treatment Plan click the Comment/Modify Plan hyperlink under Outline Actions.

3. You will receive a message asking if you are sure you want to modify the Treatment Plan. If you want to make any comments or changes click Yes. If not, click No. Both will return you to the Outline screen. If you clicked yes you will see hyperlinks next to each item allowing you to add comments, modify the item, delete or add items to the treatment plan. If you clicked no the screen will remain the same.

4. As you modify the items, you will be able to see your changes coded in color according to the key above.


Treatment Review – Plan Outline

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Treatment

1. The Treatment Review you entered will have a status of

Pending until you apply the changes.

2. To apply the changes to the Treatment Plan click the Apply Changes hyperlink. (All treatment team members must have signed off before you can apply changes)

3. You will receive a warning message asking if you are sure you want to apply the changes.

4. If you click yes, a new treatment plan will be created with the changes and the status of this Treatment Review will be Completed (Changes Applied).

5. The new treatment plan’s status will be “Active, not signed off”.

6. If you want to cancel the review, click the Cancel Review hyperlink.

7. You will receive a warning message asking if you are sure you want to cancel the review.

8. If you click yes, the status of this Treatment Review will be Cancelled and a new treatment plan will not be created based on this review.

Note that the Treatment Plan Review report can be printed from the Profile screen by clicking “Print Report” in the top banner bar.


Treatment Review

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Treatment


Medications is designed as a tool to track the meds

that a client might be taking. It is not required.

Getting here: Click on main menu item Treatment, and the submenu for Medications.

1. Clicking on Medications in the menu brings up the first screen which is divided into three parts. Active (current) Medications are displayed in the grey box at the top. The list displays medications that have been given; the Print action allows a prescription to be printed for signature.

2. By clicking Add New, the lower portion of the screen becomes editable and a new Medication may be entered.

3. Select the type of medication from the first drop-down next to Medication and then select the name of the medication from the second drop-down box for Medication.

4. Type the name of the physician and select appropriate item from other drop-down boxes.

5. To add more medications to the list, click on Add New Medication link and follow the same steps.

6. Click on Finish when you have entered all the medications that the client is currently taking.

7. Discontinuing a medication can be done by clicking on Review next to that medication under Actions.

Medications

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Encounters and NotesThe Encounter screen can be found under

the Activity List/Notes menu item.1. Click on the Notes menu and click

on the Encounters menu.

2. You may search for existing encounter records or add a new one by clicking on the Add Encounter Record link.

3. Fill out all the information on the Encounter Profile screen and click on the next arrow.

4. The next screen allows you to enter a note as well as indicate client progress, and associate goals and objectives.

5. To add a goal from the client’s active and signed off treatment plan, click on Add Goals.

6. To add an objective from the client’s active and signed off treatment plan, click on Add Objectives.

7. Signed notes are read only and appear in the gray box. To add more notes, add them to the “unsigned notes” box. If you are authorized, sign the note.

8. Click SAVE to complete your Encounter, or FINISH to return to the list screen,


Encounter Goals and Objectives

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1. While in the context of a client activity, click on the Consent menu item. This will display a list of all consents made for the client. Click Review to review any consent.

2. If you wish to add a new consent, click Add New Client Consent Record on the Client Consent List.

3. If you are viewing a current consent, you’ll notice that once the consent has been signed by the client, it is read only.

4. From an existing Consent, you can create a referral, or you can revoke the consent.

Consent

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1. Enter information on the Client Disclosure agreement.

2. You can consent to any agency within I-SMART, or to a non-system agency. The consent date is critical as it drives the date of information available (if the consent is for today’s date, any activity done yesterday will not be included in the scope of the consent).

3. Before the consent is finished and signed, the “signature” box should indicate “no”.

4. Use the Client Information Options box to select items to consent. Consents must expire upon a certain date or condition. Use the right-facing arrows to move the Consented Items over to the Disclosure Section.

In the Agency Disclosure Agreements set up, your Agency Administrator has the ability to set up defaults for the agencies to which you might consent information.


5. Once you are finished, click Save. Click on the Print Report icon at the top of the page; the consent form will pre-populate with all information. You can print it for client signature.

6. Once the client signs the consent form, change “Has the client signed the paper consent form” to YES. Click Save. The record will become read only.

Creating New Consent


1. You may create a referral by clicking on Create Referral Using this Disclosure Agreement. A referral can also be created through the Referrals menu item within a client Activity List.

2. Complete required fields on the Client Referral in the Referred By column as well as in the Referred To column. For “Continue this Episode of Care”, you should answer “No”, unless you are transferring the client to a new agency. Note that you have the option of indicating an appointment date.

5. Click Save or Finish. The referred-to agency will know about the referral as they will have a message on their home page.


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Creating a Referral

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Consent and Referral 1. The home page displays a message indicating the

number of Referrals into the agency.

2. To find clients that have been referred into the agency, go to Agency -> Referrals -> Referrals In on the left hand menu.

3. Use the Search criteria to search for referrals in. You can narrow the search by Referral Status Codes (using the right pointing arrow to move them to the Search Criteria box) or you can search for all referrals in by clicking Go.


Accepting Referrals


4. Once you click Go,

the system returns all appropriate items.

5. Click on Review to view the referral you wish to see.

6. Referrals are always sent with a Referral Status of “Referral Created/Pending”. It is up to your agency to change the status, either rejecting the referral or accepting it by choosing the status of “Placed/Accepted”. Click Finish.

Note: All other information for this referral is read-only.


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Accepting Referrals

Consent and Referral 7. Once you accept the referral, you

will be taken to the client profile screen for that client. This is a direct copy of the client profile information in the Referred-from Agency.

8. If information was transferred to your agency, the intake will be created, and the admission will be copied. In addition, the current treatment plan, fee determination and Mental health Assessment will be transferred as read only.

9. You may update the client profile if necessary. Note that the Unique Client ID will be carried over from the first agency. It is not recreated and remains the primary method for linking clients across all agencies in the State.

10. If you wish to view the activities that have been consented to you for this particular client, you must query on the client in the client search screen. Go back to the client list screen, and query on the client name or other identifier.


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Accepting Referrals

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GAIN Short Screener

Each time another agency consents information to your agency, a row will be displayed on the “Clients with Consents from outside agencies.”

In the case to the right, Daisy Duck has consented that information from Community Connections be shared with your agency.

You can view consented information by clicking on the “Activity List” action.

If the client is referred to your agency, and you accept the referral, the client will be created in your agency. If he or she did not already exist in your agency, the consent record shown will be “linked” automatically to the record in your agency.

You can now view the consented activities from the row on the client list, by clicking Linked Consents.

This will bring you to a list of all Consents for the client that have been linked together. You may view each activity list from there.


Linked Consents

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GAIN Short Screener

Users with a Clinical Supervisor role may manually link and unlink consents.

This action is available when it is clear that a client with consented information is in fact the same person as a client that exists in the agency. They may not have been automatically linked because the names or other identifying information may have been different in the sending agency than they are in the receiving agency. In this example, the supervisor may know that Daisy Duck and Daisy Duke are the same person.

Click the “link” action to navigate to the linked consents screen.

Search for the appropriate client in the HOME agency (receiving agency); in this case, Daisy Duck.

Click “Link”.

You will be asked to confirm your link.

Notice that the record that was manually linked may be “unlinked” by the Clinical Supervisor.


Linked Consents

wits training: treatment plan, consent and referral

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