Permissions: Therapist can make Addendums for their assigned Cases, Administrators or higher can make Addendums for all Cases.
To begin the Client EHR an initial assessment is made and diagnostic codes are added to the assessment. You also have the ability to classify codes as Primary, Secondary, Tertiary and Quaternary. Diagnosis codes and their classifications will appear on initial assessments and progress notes. The Diagnostic Impressions include diagnosis codes which are used for the client record and are linked to Progress Notes and Billing.
IMPORTANT: The Initial Assessment and Diagnosis Codes should be completed followed by Treatment Plans prior to the creation of Case or Progress Notes.
Complete Initial Assessment & Diagnosis Codes
- Locate Client and open Client Profile.
- Click Notes.
Select individual Case if multiple cases are listed.
- Click the Initial Assessment and Diagnostic information tab. Learn more.
- Click + Add Diagnosis to enter and classify a new Diagnosis code.
- Start typing keywords or a diagnosis code number to display diagnosis codes and select the desired code.
Click + Add Diagnosis and repeat process to add another diagnostic code if needed.
NOTE: You cannot free text to enter new codes or edit existing codes. Only codified diagnosis codes will be available.
- Complete remaining fields as needed.
NOTE: Client Intake Date may not be changed here. If the intake date is incorrect, go to Client Details > Additional Details tab to change the Intake Date.
- Click Save.