Chemical Dependence Work Areas Complete Assessment and Non Prescriber Notes
Index
- Sections
- Non Prescriber Work Areas
- Prescriber Work Areas
ICANotes offers the option to use Chemical Dependence Work Areas across all locations/sites within your practice. We also offer the option to select which locations to use the Chemical Dependence Work Areas with. If you would like to have Chemical Dependence Work Areas or Chemical Dependence Work Areas By Site, please have a Security Administrator reach out to our Support Team at 443-569-8778 or email ticket@icanotes.com to request one or both of these Group Rules be enabled.
As with all other note types, we recommend starting at the top left and working down and to the right when the Chemical Dependence Work Areas are used. Providers are able to add as much information as they would like using the Shrubs, Custom Buttons, free text or a combination these options.
ICANotes has different options for Chemical Dependence Work Areas based on your Discipline. Non-prescribers will see the options below when using Chemical Dependence Work Areas in a Complete Evaluation of your discipline. The second portion of this guide will show the Prescriber view.
Non Prescriber Work Areas
The account used for the images in this section had Counselor discipline. Select from the Shrubs along the right to add content, or customize your note content with Custom Buttons. Follow this workflow throughout all of the tabs in the Complete Evaluation.
The Problem Tab allows you to document the symptoms that the patient is experiencing, Gender/Sexual Orientation and Circumstances Leading Up to Treatment.
The Past Psych, Hist. Tab allows you to document on psychiatric treatments the patient may have had.
The Medical Hist. Tab allows you to document any medical diagnosis, current medications, past medical history, dental history and Primary Care Provider.
The Social Hist. Tab allows you to document on the patient's social, cultural and family factors that may influence them.
The Sexual History Tab is not available for Prescribers, this tab focuses on behaviors relating to the patient's sexual history.
The Family MH Hist. Tab allows you to document any known family mental health status, treatment, diagnosis, etc..
Mental Status Exam allows you to document the patient's mental status.
Finalize your Complete Assessment/Evaluation on the Inventory tab. Be sure to click on 'Compile This Note' to save all of the content in a printable layout.
Prescriber Work Areas
The account used for the images in this section had Nurse Practitioner discipline. There will be different content available in the Shrubs in many of the tabs shown in the Prescriber Work Areas. Select from the Shrubs along the right to add content, or customize your note content with Custom Buttons. Follow this workflow throughout all of the tabs in the Complete Evaluation. Several of the tabs for the Prescriber Work Areas will share names with the Non Prescriber Work Area, but will have more content.
The Hist. Present Illness tab will not carry content forward from previous Assessments/Evaluations. This tab corresponds with the Problem Tab available to the Counselor discipline shown above.
The Past Psych, Hist. Tab allows you to document on psychiatric treatment or hospitalization the patient may have had.
The Medical Hist. Tab allows you to document any medical diagnosis, current medications, past medical history, dental history and Primary Care Provider.
The Social Hist. Tab allows you to document on the patient's social, cultural and family factors that may influence them.
This tab replaces the Sexual History Tab that the Counselor discipline showed in the previous section. You can document your patient's gestational history (if known), pregnancy history (if relevant) and additional developmental content.
The Family MH Hist. Tab allows you to document any known family mental health status, treatment, diagnosis, etc..
Mental Status Exam allows you to document the patient's mental status.
Finalize your Complete Evaluation on the Finish Initial tab. You can add or update a Diagnosis Code, Add Medications and Add a Service Code for billing, add medications, etc.. Be sure to click on 'Compile This Note' to save all of the content in a printable layout.
Michelle Tinsley
Support Supervisor
443-569-8778
<img class="CToWUd" style="border: 0px; vertical-align: middle;" src="https://ci6.googleusercontent.com/proxy/L09fPjDeIqyOR2I14Yvpex5hXxTvw3Pfw_0eXLU3inrjf8JfQEreipE6E6az7-MiTdp--nXwmI-gc9Uxn__JUOGj0ksoYbU3tNplvZ3UDy63i3jBOWmuao8kuw=s0-d-e1-ft#https://app.teamsupport.com/Wiki/WikiDocs/622114/images/smalll
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