Clinical Overview: Complete the Assessment, TP, & PNs

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1. Open the patient’s chart (you can get to the patient’s chart several different ways).
   • From the My Client List, you can left-click on the patient’s name to open the chart.
     
     
      
   • From the Available Forms list select the appropriate “Comprehensive Assessment” form.
     
     
2. Complete each of the required fields in each tab on the form.
   • In the Needs tab create a prioritized need.
     
     
      
3. From the Available Forms list select the appropriate “Treatment/Recovery Plan”.
   • Complete Goals tab and click the Save button.
4. For each goal, enter the required information and click Add/Update.
5. The goal will then appear in the goal table.
   • The below example demonstrates ONE goal being entered.  However each treatment plan can have multiple goals AND for each goal there can be MULTIPLE Objectives.
     
     
      
6. Complete Objectives tab and click the Save button.
   • You are required to enter at least one Objective for each Goal.
   • You can enter more than one objective per goal.
7. Select the goal from the table and enter the required information for the objective.
8. For each objective, enter the required information and then click Add/Update.
9. The new Objective will appear at the bottom of the form.
   
   
    

View Goals (Read Only) tab

• This tab contains each Goal you create along with the associated Objective(s).
• It displays the information entered in a listed form.
• This tab is read only and cannot be edited.
• This tab is updated every time you create a Goal/Objective and Save.
  
  
   

1. From the Available Forms list select the appropriate “Progress Note - Mental Health note”.
2. Complete Goal/Objectives Tab.
   • The Goal that was created in the above steps will appear in the Goal pull down menus.
3. Complete all required fields to write the progress note that captures the results of the session or service.
   
   
    

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