Step 2: Document Clinical Message for Client

The Clinical Message screen appears as shown below. Use this screen to document information received on behalf of the client, including communications from external contacts. You can use the available action buttons to quickly insert recorded details into the yellow message box.

Refer to the field descriptions below the screenshot for more information about each item on the screen.

1. Message Taken By: Select from the dropdown list to indicate who is documenting the message.
2. Message From: Enter the Message From field to capture the name of the person leaving the message.
3. Basic message was: Provide the basic message details to summarize the message content.
4. Call back: Specify a call back number if a return call is requested.
5. Action taken, if any: Note any action taken, if applicable.
   

Documenting Client Call Information

1. Home Phone: Auto-filled if available; enter manually if blank.
2. Work Phone: Auto-filled if available; enter manually if blank.
3. Cell Phone: Auto-filled if available; enter manually if blank.
4. Email: Auto-filled if available; enter manually if blank.

Caller Contact Information (other than client's)

Use this section to enter the caller's contact details if the caller is other than the client.

1. Caller's Name: Enter caller's name in this field.
   
2. Home Phone: Enter caller's home phone number.
   
3. Work Phone: Enter caller's work phone number.
4. Cell Phone: Enter caller's cell phone number.

To insert all caller's details into the message box, click Add All. To insert an individual field, click the plus (+) icon next to it.

Documenting Client Contacts

Use this section to record important contacts related to the client's care, such as their primary care physician, outpatient providers, or pharmacy. 

Enter the phone and fax numbers for each contact as needed. To insert all contact details into the message box, click Add All. To insert a specific contact, click the plus (+) icon next to it.

1. Primary Care Physician
   
2. Outpatient Psychiatrist
   
3. Outpatient Therapist
   
4. School Contact
5. SASS Contact
   
6. Pharmacy

Using Action Buttons

Use the action buttons below to quickly insert common phrases into the yellow message box. After clicking a button, the phrase will appear in the message box, where you can add further details as needed.

Available buttons include:

1. Please Call
   
2. Left Message
   
3. Faxed To
   
4. Please Fax To

Creating Message Using Action Buttons

The message shown below has been created using two action buttons. You can combine multiple buttons as needed to build customized messages efficiently.

Documenting Refill Details

The Refill Called In Form allows staff to document prescription refill requests received from a client’s relative, caregiver, or other representative. This structured form ensures refill approvals and appointment information are accurately recorded in the client’s chart.

The Refill Called In Form appears as shown in the screen below:

1. Rx Called In by: Select the name of the person who called in the prescription refill on behalf of the client.
2. Call-in Approved by: Select the staff member or clinician who approved the refill request.
3. Last Kept Appointment By: Enter the date of the client's most recent completed appointment.
4. Next Appointment Is: Enter the scheduled date of the client’s upcoming appointment.
5. Other Comments: Add any relevant details regarding the refill or the communication received (e.g., prescription details, urgency, pharmacy information, etc.).

Once all details are recorded, click the Enter this information into Text button to insert the information into the yellow message box for further review or editing.

Documenting Mental State Exam

In the Mental State section, you can use quick action buttons to record information related to anxiety. To access the complete list of mental state exam items, select See List, as shown in the screenshot below. This opens the Mental Status Exam tab, where you can document detailed observations.

The recorded information appears in the shrub on the right.

Creating Custom Content

The Clinical Message feature also allows users to create custom content that can be inserted into the yellow message box as needed.

Adjusting Content in the Yellow Box

After inserting details into the yellow message box using the action buttons, you can further edit the text as needed. Use the formatting toolbar at the top to apply styles such as bold, italic, underline, and more to enhance readability.

Step 3 (Optional): Filter Clinical Messages

Use the filter at the top of the chart face to display only the clinical messages recorded for the client.

Step 4: Compile and Preview Clinical Message

1. Capture an electronic signature
2. Navigate to related work areas
3. Generate an invoice
4. Create a clinical or discharge summary
5. Download or print the clinical message as needed