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Documentation that never gets old!

Documentation that never gets old!

posted by: Nicole Hovey date: Mar 26, 2019 category: Blog comments: Comments Off on Documentation that never gets old!

BestNotes Profiles

  • Ready-to-use Clinical Documentation
  • Audit & Accreditation Compliant
  • Pre-programmed for Intelligent Movement of Data
  • Automatic Updates

The Behavioral Health and Addiction Treatment Profiles were created to eliminate anxiety about new regulations and audits. The clinical documentation and workflows of the profiles adhere to common State regulations, UnitedHealth’s (Optum) level of care guidelines and audit tools as well as standards recommended by The Joint Commission and CARF. Our in-house Clinical team has worked hard to maintain an efficient workflow by eliminating redundancies and double-data entry. The best part – BestNotes will automatically update and maintain this documentation for you!

Addiction Treatment Profile Content

Admissions/Intake
Online Patient Application and Pre-Screen
Level of Care Criteria (Dimensional Crosswalk)
Assessments
Comprehensive Diagnostic Assessment (Multi-Dimensional Format)
History and Physical Exam
Psychiatric Evaluation
Nursing Assessment
Treatment Planning
Master Treatment Plan
Utilization Review
Discharge Summary
Delivery of Care
Progress Notes: Clinical (DAP & SOAP Styles), Psychiatric, Nursing, CBRS, Peer Support, and Case Management
Group Therapy Note
Drug UA Results Note & Report
Operational Support
Collaboration of Care Note
Missed Service Note
Treatment Team Note (Staffing)

Behavioral Health Profile Content

Admissions/Intake
Online Patient Application and Pre-Screen
Assessments
Comprehensive Diagnostic Assessment
Psychiatric Evaluation
Nursing Assessment
History and Physical Exam
Peer Support Assessment
Recovery Coaching Assessment
Treatment Planning
Master Treatment Plan
Discharge Summary
Case Management Plan
Skill Building (CBRS) Plan
Peer Support Plan
Recovery Coaching Plan
Delivery of Care
Group Therapy Note
Progress Notes: Clinical, Psychiatric, Medical, Nursing, CBRS, Family Support, Peer Support, Recovery Coaching, and Case Management
Operational Support
Missed Service Note
Collaboration of Care Note

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