NYSCRI Comprehensive Treatment Plan Review v2 (NYIAPRv2)

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Form Details

• Form Properties
  1. Form Title: Phase 2 Brief Medical Screening v2
  2. Start from an Existing Form - Yes, if there is a previous version signed and locked.
  3. Copyrighted Form - No
  4. Billable Progress Note - No
  5. Have multiple versions open at same time - No
  6. Open Blank on new version - No
• Required Fields - None
• Lookup Tables - None
• Pre-Fill Logic
  1. Organization Name will prefill from Setup †’ Program/Billing Defaults > Company Info Tab.
  2. Program Name will prefill from the Program the patient enrolled in.
• Fill to Logic - None
• Signatures
  1. Individual Served Signature (Optional)
     • Sig type: Patient
  2. Parent/Guardian Signature (Optional)
     • Sig type: None
     • Name needs to be entered.
  3. 3Staff Signature
     • Sig type: Any
     • Route-To available.
     • Signature locks the form.
  4. Supervisor / QHP Signature
     • Sig type: Supervisor / QHP
     • N/A box defaults to unchecked.
     • Route-To available.
     • Signature locks the form.
  5. NPP/QHP Other than CASAC Signature
     • Sig type: NPP, QHP, Other than CASAC, NP-non CASAC
     • N/A box defaults to unchecked.
     • Route-To available.
     • Signature locks the form.
  6. Psychiatrist/Medical Staff Signature
     • Sig type: Physician, Psychiatrist, DO, MD
     • N/A box defaults to unchecked.
     • Route-To available.
     • Signature locks the form.
  7. Staff Signatures (4)
     • Sig type: Any
     • N/A box defaults to checked.
     • Route-To available.
     • Signature locks the form.

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Goals Tab

1. Prefill - Organization Name will prefill from Program/Billing Defaults (see Program/Billing Defaults).
2. Prefill - Program Name: Program name will prefill with program name patient is in enrolled in.
3. Review Date - Will auto sync to date form is locked.
4. Next Review Due By: Date will calculate and populate when locked based on date parameters set in Program/Billing Defaults - treatment plan defaults (see Program/Billing Defaults).
5. Review/Revision - Select if completing a review or revision.
   • Selecting Review will open all Goal / Objective fields for creating a goal/objective.
   • Selecting Revision will open limited fields on the objective tab for editing: Interventions, Service Description, Frequency, Responsible Party Summary of Progress.
     • Selecting Revision will not alter Review / Next Review Due dates.
6. Goal: Goals from previously completed plan will prefill to plan review.
   • Select the Goal from the Goal grid to fill fields.
   • Goal number will show in Goal field.
7. Goal Statement: Goal statement will show.
8. Goal Determination: Select one of the following:
   • Continued: Will change the goal status to continued and allow you to enter an adjusted target date.
   • New: Will clear all goal text and date fields to enter another goal.
   • Discontinued: Enter the date the goal was discontinued.
   • Attained: Enter the date the goal was attained.
   • Revised: Will change the goal status to revised and allow you to edit all goal text and date fields.
9. Start/Target Date will auto fill.
10. Adjusted Target Date: Enter adjusted target date if adjusting the target date for the goal.
11. Per IAP date: Will auto fill and sync to locked date.
12. Goal Details: Will auto fil from last completed plan.
13. Add/Update: Select to Update Goal into grid.
14. New: Select to clear Goal fields.
15. Remove: Select to remove Goal from grid.
16. Goal Grid: Goals display in the grid.

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Objectives Tab

1. Goal: Goals from Goal tab will populate in the Goal grid box.
   • Select the goal objective is to be associated to.
2. Goal# will prefill based on goal selected in the grid.
3. Objective: text field, assign Objective letter.
4. Objective Description: text field, enter objective statement.
5. Objective Type: select an objective type.
   • Continued: Will change the objective status to continued and allow you to enter an adjusted target date.
   • New: Will clear all objective text and date fields to enter another objective associated to the goal.
   • Discontinued: Will change the objective status to discontinued.
   • Attained: Will change the objective status to attained.
   • Revised: Will change the objective status to revised and allow you to edit all objective text and date fields associated to the goal.
6. Start Date / Target Completion Date: Dates will prefill from the last completed plan.
7. Adjusted target date: Enter adjust target date (not typically used on the first plan).
8. Objective details: Fields will prefill from the last completed plan.
9. Summary of Progress: text field, enter a summary of progress.
10. Add/Update: Select when object completed. Selecting will add the objective to the Objective grid.
11. New: Will clear all objective text and date fields to enter another objective associated to the goal.
12. Clear: Will clear all objective text and date fields with exception of Objective letter, objective statement and Start/Target Date to enter another objective detail associated with the Objective letter/Objective Statement.
13. Remove: Will remove the objective from the grid.
14. Objective grid

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Goals (Read Only) Tab

1. No input. Goals will be listed here.

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Patient Info Tab

1. Methadone Programs Only- Enter the attendance schedule and daily dosage.
2. ACT programs only- indicate the changes in individual’s status in assessed domains.
3. Transition/Discharge Criteria- Enter any changes in the patient’s transition/discharge criteria.
   • No Change- Select if there is no change in the patient’s transition/discharge criteria, this will gray out the associated fields.
   • COA Programs Only- Select the estimated length of treatment and stay.
   • Enter how the provider/individual/guardian will know that the level of care change is warranted.
4. Indicate the anticipated plan for discharge, including Tx., support services, community resources.
5. Select if the individual has participated in the development of this plan.
   • If NO, provide a reason for why not.
6. Select if other(s) participated in the development of this plan.
   • If YES, list the names.

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Signatures Tab

1. Signature Credentials (see Credentials)
   • Individual Served Signature (Optional)
     • Sig type: Patient
   • Parent/Guardian Signature (Optional)
     • Sig type: None
   • Staff Signature
     • Sig type: Any
     • Route-To available.
     • Signature locks the form.
   • Supervisor/QHP Signature (Optional)
     • Sig type: Supervisor/QHP
     • Route-To available.
     • Signature locks the form.
   • NPP/QHP Other than CASAC Signature
     • Sig type: NPP, QHP, Other than CASAC, NP-non CASAC
     • N/A box defaults to checked.
     • Route-To available.
     • Signature locks the form.
   • Psychiatrist/Medical Staff Signature
     • Sig type: Physician, Psychiatrist, DO, MD
     • N/A box defaults to checked.
     • Route-To available.
     • Signature locks the form.

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Additional Signatures Tab

1. Signature Credentials (see Credentials)
   • Staff Signatures (4)
     • Sig type: Any
     • N/A box defaults to checked.
     • Route-To available.
     • Signature locks the form.

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