Table of Contents

1. Form Details
2. Session Info Tab
3. Mini-Mental Status Tab
4. Goals/Objectives 1 Tab
5. Goals/Objectives 2 Tab
6. Interventions Tab
7. Signatures Tab
8. History Tab

 

Form Details

• Form Properties
  1. Form Title: NYSCRI Psychotherapy Progress Note
  2. Start from an Existing Form – No
  3. Copyrighted Form – No
  4. Billable Progress Note – Yes
  5. Have multiple versions open at same time – No
  6. Open Blank on new version – Yes
• Required Fields – Yes
• Lookup Tables – Yes
  1. Code will pull from Facilities.
  2. Service Code will pull from Visit Types.
• Pre-Fill Logic – Yes
  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.
  3. Goals/Objectives will prefill from the most recent completed Treatment Plan.
• Fill to Logic – None.
• Signatures
  1. Individual Signature
     • Sig type: Patient
  2. Guardian Signature
     • Sig type: None
  3. Staff Signature
     • Sig Type: Any
     • Route-To is available.
     • Signature locks the form.
  4. Supervisor Signature
     • Sig type: Supervisor
     • N/A box defaults to checked.
     • Route-To is available.
     • Signature locks the form.

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Session Info Tab

1. .Select Date of Service
   • Indicate Start time/end time.
     
     • Will calculate the duration.
2. Select Service Code.
3. Indicate Modality.
4. Document all Individual Present.
5. Describe Individual’s Progress.

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Mini-Mental Status Tab

1. Document individual’s Mini-Mental Status.
   
   • Grey out – Selecting notable will open the text field.
2. Describe any New Issues/Stressors/etc.
   • Grey out – Selecting none reported will grey out the text field.

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Goals/Objectives 1 Tab

1. Enter Goals & Objectives – minimum of one.
   • Prefill – Goals/Objectives pre-fill from completed Individualized Action Plans.
   • Selecting N/A will grey out the goals/objectives drop downs.

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Goals/Objectives 2 Tab

1. Continue to enter Goals & Objectives.

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Interventions Tab

1. Describe Interventions provided.
2. Describe Individual’s Response to Intervention.
3. Describe Plan.

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Signatures Tab

Signature Credentials (see Credentials)

1. Individual Signature
   
   • Sig type: Patient
2. Guardian Signature
   • Sig type: None
3. Staff Signature
   • Sig Type: Any
   • Route-To is available.
   • Signature locks the form.
4. Supervisor Signature
   • Sig type: Supervisor
   • N/A box defaults to checked.
   • Route-To is available.
   • Signature locks the form.

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History Tab

1. No input.  Individual’s progress note history is displayed.

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