Clinical Training Manual

The Clinician Dashboard is a one-stop page for clinicians to see client events for the day, documentation that is coming due, due or overdue and the day’s appointments.

Client Events

Client events can be defined as outside appointments that the clients must attend, such as a doctor’s appointment or an appointment with his or her Probation/Parole Officer. By clicking on the blue ribbon, you can expand and collapse this section.

Documentation Due

This section informs the clinician of documentation that is due for the day, coming due or past due. It also includes several filters where the clinician can search for documentation for a specific client, form or program. Finally, the clinician can schedule a service with a specific client from this page using the schedule link. By clicking on the blue ribbon, you can expand and collapse this section.

The top of this part of the dashboard helps the clinician filter the documentation so that the documentation can be viewed several different ways.

On the left side of the dashboard, there are drop-downs and ellipse buttons. The clinician can use one or several of the filters to find a specific document. The clinician can filter by:

specific program. If the clinician works with several levels of care, he or she may only want to look at forms that are coming due, due or overdue by one of those levels of care.

specific form. If the clinician wants to only see treatment plans that are coming due, due or overdue, he or she can use the ellipse button to choose a specific form type.

specific client. If the clinician wants to only see what forms are coming due, due or overdue for a single client, he or she can use the ellipse button to choose a specific client.

Forms Due By. Currently, the system will only look 30 days into the future for forms coming due, due or overdue. If the clinician wishes to look further into the future, he or she can change the Forms Due By to any date in the future. If he or she is expecting a certain form to be due, he or she can change the date to see when exactly the form is going to be due.

On the right side of the dashboard, there are more filters which can be chosen via radio buttons. The clinician can filter by:

form type. Not only can the clincian filter by specific form type, he or she may also filter by looking for only regulated forms[1], forms required to Complete the Day[2] or All forms. The default for this section is set to All.

clients. The clinician can choose to look at his or her clients – where the clinician is on the list of internal caregivers or the primary therapist on a service or by all clients.

signing sequence. Many times, forms need to be signed by multiple staff members or client/guardian. The signing sequence has been determined by Administration. The clinician can look for forms that require their signature, forms that may need his or her signature in the future, forms that they have already signed but are awaiting a signature from another staff member or All forms regardless of signing sequence. The default is set to My Turn to Sign. In order to sign a form from the Clinician dashboard, the clinician must click on the Edit link next to the form they wish to sign and click the SIGN button on the form.

Today’s Schedule

This part of the Clinician Dashboard shows the clinicians any appointments or activities that are occurring that day. The clinician can use the Add link at the top of this section to add any appointments to the day, open the Service Activity, look at the Treatment Plan for a specific patient or complete any documentation that is related to a Service Activity.

Clinician Schedule

The Clinician Schedule can be viewed by day, week or month. Administration will set up the activities that can be used with the scheduler and may also assign a background color and text color for different types of appointments. From the Clinician schedule, the clinician can access a specific service activity, reschedule an appointment, provide the client with a receipt for services, set up a recurring appointment for a specific client and complete the documentation. The Clinician Dashboard also alerts the clinician is a co-payment is due at the time of service.

By clicking on the Service, the clinician will be taken to the Service Activity page, where he or she can change the Staff or Patient Status for the appointment and also complete any documentation that is required for that service.

Looking at daily, weekly or monthly schedule

By using the tabs at the top of the Schedule page, the clinician can look at his or her schedule by the day, the week or the month. The clinician can use the arrow buttons next to the date, week or month to look forward or backwards.

Service Activities and Documentation

Using Service Activity to Complete Activity and Complete Documentation

When the clinician has provided a service to the client, the clinician can open the Service Activity screen by clicking on the service on his or her schedule in order to set the appropriate Staff Status, Patient Status and completed any required documentation.

Administration can connect a specific form with a specific activity. If the form is tied to a service, there will be a two links on the far right of the Associated Patient Section that reads View Form or Change Form. In order to complete this documentation, the clinician must click on the View Form link. From that point, the documentation will open in a new window and can be completed. If the document is not appropriate for the activity, the clinician can choose another form[3].

If Administration chooses not associate a specific form with a specific activity, the clinician will see a form link that reads Add Form. When he or she clicks the Add Form link, a new window will open with a drop-down list box. Using the drop-down list box, he or she can choose the form that is appropriate for the service.

Common Phrases

Administration can create Common Phrases that can be used in Progress Notes. In order to use a Common Phrase is to click the cursor where you wish to input the Common Phrase and choose the appropriate phrase but clicking on it. The clinician can type information before using the Common Phrase, can type information after using the Common Phrase or edit the Common Phrase. It is suggested that the Common Phrases remain limited in number, as if the list is too long, the clinician will spend more time looking for the phrase than he or she would if he or she just typed the sentence.

Collecting signatures via signature pad or touchscreen

Oftentimes, a form will require a Client Signature and/or a Parent or Guardian Signature. There are currently two ways that a client/parent/guardian can sign forms. If the clinician has a Signature Pad, he or she can click on the SIGN button and a new window will appear allowing the client to use the stylus or fingernail on the Signature Pad to write his or her name.

The second way that a client/parent/guardian can sign a form via a TouchScreen. In order for the client to sign the form, he or she can use a stylus or fingernail to sign on the touchscreen. If he or she is not happy with the look of the signature, the clinician can click on the CLEAR button. If the client is satisfied, the clinician can click on the ACCEPT button.

Signing with username and password

Most forms require a staff signature. There is a SIGN button at the bottom of each page of the form that allows staff to sign the form using his or her username and password. Once the clinician has entered his or her username and password, click on the Submit button. If the clinician has more than one role within the system (for example, Supervisor and Clinician), he or she can choose with which role he or she would like to sign by using the Sign As drop-down list box.

There are many forms that require multiple signatures from staff. The system must have all signatures in order for the form status to be considered Completed. Often Administration will sequence the signatures so that for example, the clinician if the first to sign. Once he or she has signed the form, it will be removed from his or her dashboard and will appear on the sequenced staff’s dashboard for review and signature.

In order to see the Required Signatures for a specific form, clicking the View Signatures button will provide details regarding who has already signed the form and who needs to sign the form.

Generating a Narrative

Some forms will have a narrative that is generated from the information entered in the form. Administration has determined which forms should generate a narrative and which forms should not. The narrative is built as a separate form. A narrative uses the information in the form to create sentences based on the answers provided by the client. A narrative is a way to provide information to others, including an outside agency with read-able and coherent overview of the information provided by the client. There are also required signatures that accompany narratives.

Setting Staff Status to Completed as Planned (changes patient to Completed)

Once a service has been changed from Pending, the clinician can enter the status of the service via the Status drop-down associated with staff person who provided the service. The clinician understands that how he or she changes the status will reflect on the Status of the client for individual or family sessions only. If the Staff Status is set to Cancelled, it means that the staff member cancelled the service, not the client. If the clinician chooses did not attend, that means that the specific staff member did not attend the service. When the clinician sets the Status to Completed as Planned and updates, it will set the same status on the Associated Patient only for individual or family sessions where there is only one identified client.

Alternately, if the client did not attend the session or cancelled the session, setting the status on the Associated Patients will reflect that the client did not attend or the client cancelled the session.

Other Associated Staff

There are times when the clinician assigned to an activity is not able to attend or complete the activity. In order for another clinician to complete the activity, he or she must be added to the Other Associated Staff. In order to add a staff member to an activity, click on the Add button and choose the appropriate staff person. By adding an Associated Staff, the activity will appear on the schedule of the chosen staff member.

Finally to reassign the activity, the Primary Therapist field must be changed to the Associated Staff in order for the newly added associated staff can change Patient Status(es) and complete the associated documentation.

Differences between working with activities with a single Associated Patient and multiple Associated Patients

Group Sign-In

If the clinician is facilitating a group, he or she can have clients sign in to group using the Sign-In button. The clinician must have a Signature Pad at this time to allow the clients to sign in to the group. There is also the ability to mark a client as tardy, using the checkbox next to the Sign-In button.

Once all the clients have signed it, it is possible to update, view and/or print the sign in sheet by clicking on the Sign-In Sheet button below the list of Associated Patients.

Setting Patient Status on Groups

As setting the Completed as Planned status will change the Associated Patient status for individual sessions or family sessions where there is only one identified client, the clinician must change the status of group members individually. The system does not know inherently who came to the group and who did not attend. Once all the statuses have been set, the clinician can use the Update button beneath the list of Associated Patients.

Adding Documentation for a Group

Many times, Administration will differentiate an individual/family note with a group note. Group notes can include a general group note which will enter the same information in the same field for every client that attended the group. If Administration has chosen to have a specific group note, the clinician will see a link that reads Add Group Note instead of Add Form/View Form/Change Form. By clicking on the Add Group Note, the clinician will choose the appropriate group note. A new window will appear with the name of the group note and the name of the field that will fill in every group members note.

The clinician will type information into the field(s) and click on the Add button. This will send the information typed by the clinician to every group note with that field. Once the clinician clicks the Add button, he or she will be taken to the original Service Activity page where the Add Group Note link has changed to View Form/Change Form links. In order to individualize, the clinician may then go into each note using the View Form to add information specific to the patient and sign the form.

Completing documentation

Forms are built within an external program and imported into Epitomax. The team at Epitomax has worked with Administration to determine how the form should function.

There may be areas of the form that are free text, radio-buttons, check boxes or drop-down list boxes.

Depending on how the form is set to function, information can be pulled from other parts of the system and automatically entered onto the form.

Administration can also decide which fields on a form are considered required. A required field is typically differently colored – usually some hue of blue-green (as seen on the above form by the field “Action Taken”. The form cannot be signed by any person (client or staff) until the required fields have information in them. If the client or staff attempts to sign the form prior to entering information in the required fields, a window will appear that explains that signatures cannot be collected until certain fields are filled in. The window will display the field names and page in red so that the clinician can go back and fill in that specific field.

Sign – This button allows any staff member to sign a form electronically – with username and password. Even if the staff is not entered as an Internal Caregiver, they may still sign the form.

Add Client Signature*- This button allows the clinician to add a Client Signature that will flow through to the Patient Portal automatically.

Update – This is potentially the most important button when it comes to completing documentation. The clinician must update after completing any page of documentation. By updating a page, the system knows to save the information on that page to the database. If the page is not updated, any work will not be saved and the clinician will need to re-enter all the information on the page. Often, if a change has been made to a page and the clinician tries to move to the next page without updating, the system will pop-up a window with a reminder to update. If, however, the clinician does not make a change but the system has automatically entered information (such as using a form link or using the Treatment Plan Review functionality), the system does not pop-up a warning.

History – This button allows the view a history of documentation of the same form type. By clicking on the history tab, a window will open that will allow the clinician to view past completed or pending documentation by clicking on the date of the document.

View Signatures – This button allows the clinician to view the required signatures in sequence.

Print – This buttons opens a PDF of the document, allowing the clinician to print. By using the Print link, the document does not automatically print on a local printer. The clinician must follow the same direction as if he or she were printing any normal PDF.

Diagnosis – This button opens the Diagnosis tab in a new window. This allows the clinician to change the diagnoses “on the fly” when completing the form. Upon making the change in diagnosis, the clinician can close the Diagnosis tab window.

Refresh – This button is directly related to the Diagnosis button. Upon changing the diagnosis and closing the Diagnosis tab window, the clinician can click on the Refresh button to view the newly changed diagnosis.

Close – This button closes the form.

Scheduling

Groups recur on their own

When a group is created by Administration, they set up the group schedule within the system. The clinician does not have to reschedule or set a recurrence for any group.

Reschedule an appointment

If a client or staff cancels an appointment, either with notice or without, the clinician can reschedule the appointment for a different day and/or a different time. When a service needs to be rescheduled, the clinician can view his or her schedule and use the Reschedule link to change the date or time of the service. When he or she clicks on the Reschedule link, he or she will be taken to a service activity page that includes his or her monthly schedule. In order to reschedule, the clinician can use the service activity to enter a new date and/or time. The monthly schedule is available so that the clinician does not accidently double book him or herself.

Receipting a client

In order to give a client a receipt, Administration has to provide each clinician a cash sheet. If the clinician does not have a cash sheet, he or she cannot give a receipt to the client. When the clinician clicks on receipt, the above window will appear. If the client provides cash or check, the clinician can enter how much he or she was given, whether the payment type was cash or check and set the cash sheet to reflect cash or check. The Reference No on the page is meant to reference check numbers and the clinician can enter any comments. Here the case number was included in the comments. From the receipt page, the clinician can schedule the next appointment with the client.

Setting a recurring individual sessions/family session

Reviewing Client Chart (Clinical Tab)

Assessments/Evals, Treatment Plans, Progress Notes, Miscellaneous, Discharge

Epitomax allows users to view a client’s electronic documentation organized by client admission. When services or activities are entered into Epitomax and forms are associated with those activities, those forms show up in the client’s Electronic Record.

Electronic Record

Clinical users can view and/or modify the client’s electronic record by navigating to the Clinical tab of the client’s current Admission episode. There are multiple ways of accessing the Client Record[4] and more specifically, the current Admission[5] and the Clinical Tab.

1. The clinician can utilize the Client Search under the Client Tracking menu. The clinician can enter information any of the filters and click on the SEARCH button. If the Client Search finds several clients who meet the requirements of the filter, a list will appear at the bottom of the screen and the clinician can click on the Case Number to access the specific client. If there is only one client that meets the requirements of the filter, the clinician will be automatically taken to that client’s Client Record. From the Client Record, the clinician can navigate to the Episode History tab and click on the chosen Admission.

2. The clinician can utilize their Dashboard to access a current admission by clicking on the Program link.

3. The clinician can access the current via their Scheduler. By clicking on the appointment, the clinician opens the Activity. The clinician can navigate to the Program link and click.

4. The clinician can access the current admission using the Case Load menu item from the Clinical menu. The Case Load menu only works if the clinician accessing the screen is included in the Internal Caregivers for that Admission. The clinician can click on the Program link.

Documentation

Progress Notes (as well as any other form) can be added from the Clinical tab. However, adding a form from one of the tabs under the Clinical tab will not generate billing. To document a service and generate billing from that service, see the section on Service Documentation.

There could be more forms under the tab than can fit on the screen at one time. Use the Page Next button to see the next page of forms.

The links to the right of the Form Name allow for different actions depending on the security level of the user.

The Edit link allows the clinician to make changes to any form that remains in a Pending Status. Once the Status has been changed to Completed, no staff can make any changes to the form and the Edit link becomes a View-Only function.

The Print link opens a PDF version of the form that can be printed. Using the Print link does not automatically send the form to a local printer.

Required signatures that have been fulfilled have their Role populated in the list. Users that have signed who do not meet the required signatures criteria for the given form are listed without a Role.

The Move, Delete and Edit Metadata links are utilized by Administration to move a form to another episode or another client altogether. The Delete link allows Administration to delete a form. The Edit Metadata link allows the Administration to change a form back to Pending once it has been set to a Completed Status. It also allows Administration to change the due date of a specific form. Most clinicians will not see these links on any of the documentation tabs.

Any form related to an Activity will have the Activity Status listed on the specific documents tab. A clinician can access the Activity to which the form is attached by clicking on the link for Activity Status. The clinician can make changes to the Activity, including setting a status from Pending to Completed from here.

To learn how to complete any form, please see Completing documentation.

Of special note is the functionality regarding Releases of Information. Releases can be added through the Miscellaneous tab or can be entered per External Caregiver. To learn about how to add releases per External Caregiver, please see On Episode Level under External Caregivers.

When to add forms manually vs. attached to activity

Any form that is added to the Clinical tab using the Add button will not be attached to an activity and therefore is not billable. Only add a form manually if there is not a billable activity related to it.

Other Important Tabs for Clinical Use

On Record Level

Episode History

The Episode History tab allows the clinician to view past and current Inquiries and Admissions. By clicking on the links for Admission or Inquiry, the clinician can view all the information associated with an inquiry or Admission, including any forms that have been completed or pending for the Inquiry or Admission.

Allergies/Medications

The Allergies and Medications tab allows the clinician to view any past or current allergies and/or medications. If a medication is discontinued, it will be red. These can be medications based on history, provided by other physicians or provided by the facility physician and/or psychiatrist. Without specific privileges, the clinician cannot modify the Allergies and/or Medications tab.

Alerts

Alerts can be set up by Administration to alert any staff member who accesses a client’s admission. Examples include behavioral alerts, alerts for client events (such as court dates), financial or any other type of information that staff associated with the client should know. In order to create an Alert, the staff clicks the Add button, chooses the Alert Type from the drop-down list box and include a description of the specific alert. This alert will appear when staff access the client record and can be seen on the service activity screen.

Any alert can be expired by entering a date in the Expiration Date field and clicking Update.

Documents

External documents can be attached to a client record including pictures that appear on the Patient Record Page, any referral information, copies of licenses and/or insurance cards, or homework assignments.

In order to add a document, the original document must be scanned into a computer. The staff uploading the document clicks the Choose File button and navigates to where the document has been scanned. Once the correct form has been found on the computer, staff clicks Upload File.

Appointments

Any past or future appointment can be viewed via the Appointments tab. The clinician can navigate directly to the Activity or reschedule an appointment from this screen.

On Episode Level

Authorizations if clinician works with insurance co.

If a clinician is responsible for authorizations, he or she can use the Authorization tab. From here, the clinician can view how many units of authorization are left and complete a new Authorization.

By clicking on the Edit button, the clinician can view the information specific to the authorization.

In order to add a new authorization for a client, the clinician clicks on the Add button and chooses the Payor who is authorizing the services. If there is no payor listed, the clinician must enter a Payor in the Client Record portion, not on the specific admission.

The clinician then enters all the required information and clicks on the Update button.

Diagnosis (current view of tab)

The diagnosis screen is in the middle of a major change so that Epitomax meets the requirements for the DSM-5 and the ICD-10. Currently, diagnoses are entered using the multi-axial diagnosis as per the ICD-9 and DSM-IV. Diagnoses can be changed according to the continuing assessment and treatment progress. An audit trail is available so that the clinician can follow the changes to diagnosis, including when the change was made, what the diagnosis was prior to the change and the staff member that made the change.

By using the ellipse button next to each field, the clinician can search for and choose the appropriate diagnosis. By simply entering the % symbol and a string of letters found in the diagnosis, the clinician can search for any diagnosis that includes that same string of letters.

Once the clinician clicks on the Search button, he or she can use the drop-down to find any diagnoses that includes that string of letters.

Upon finding the correct diagnosis, the clinician clicks the OK button and that specific diagnosis is added to the multi-axial diagnosis. The diagnoses are filtered by Axis and therefore, the clinician will not find any Axis I diagnoses when search for an Axis II.

In the future, Epitomax will be changing over to the new system for diagnosing.

The clinician will use the Add button to add any diagnosis, and order the list of diagnoses from most salient to least salient.

The clinician will click on the Add a New Diagnosis button to begin entering the diagnosis.

The clinician can fill in the diagnosis using the ellipse button. When this screen becomes active, the clinician will also be able to list whether the diagnosis is a rule-out, by traits, by history or by self-report. This allows the diagnosis to be increasingly accurate.

Documents

Documents allows for a place for any scanned document to reside. This could mean a state ID, driver’s license, insurance card or homework completed by the client.

Internal Caregivers

Internal caregivers tab is a list of staff members associated with the Admission, also called the Treatment Team. This tab is extremely important as any required signatures on a form looks to this information in order to place any forms with needed signatures on the correct dashboard.

Internal caregivers are added by first selecting the caregiver role and then selecting the staff person’s name.

External Caregivers

External caregivers is a list of persons or organizations (future change) who are interested parties in the client’s treatment. This can include PCPs, Probation or Parole officers, dentists, etc.

By adding a new external caregiver, the system allows you to attach a specific Release of Information for that person or organization (future change).

Once the information is Updated, the clinician will have the ability to add, edit or revoke a Release of Information by using the Release History link.

The clinician then chooses to Add a new form and sets the duration of the Release using the drop-down.

Once the duration is chosen and updated, another window will open and the clinician can then choose the appropriate form, if there is more than one type of Release. Once the form is signed, it is considered completed.

To view the Release History of any External Caregiver, the clinician can click on the Release History link. This opens a list of releases, including ability to view the status, view the form itself, and revoke the release. Revocation occurs when the clinician clicks on the Revoke link. The form also expires itself when the duration has been met.

Instances of Contact

Instances of Contact allows the clinician to keep a running list of collateral contacts. Instances of Contact can also allow the clinician to keep a record of contact made by the client.

The Instance of Contact allows the clinician to enter information from the contact including the information collected during the contact.

Alternate Contacts (esp. for Emergency Contact Info)

Alternate Contacts allows specifically the ability to select an Emergency Contact for the client.

School Info

Administration will add any information about local school districts that may have involvement with a client.

Completing the Day

Service Activity tracking in Epitomax is used to record all activities performed by Staff (both billable and non-billable activities). A day of Service Activity can be Completed after all activities have been resolved (i.e., Statuses set to something other than Pending) for that day. Once a day of activity is “Completed” for a Staff Person, then Charges for any billable services will be processed for billing purposes and the Completed day will be available for payroll processing.

To view incomplete Service Activity

The View Incomplete Service Activity function allows users to view a list of incomplete days of Service Activity for the selected staff person.

1. Click on the Service Activity Entry menu item from the Service Activity menu

2. Select the Staff Person from the Search box by using the Ellipsis

3. Click Ok

4. Click Submit

Clicking Update completes the day for any date having the Complete the Day With No Activity checkbox checked.

The list of Incomplete Days includes all records for the chosen staff between the last day charges were generated and the current system date plus 21 days. It may also include any Completed Days where Payroll and Charges have not been generated.

The Complete The Day With No Activity checkbox only displays for days where the Total Hours column equals zero and the activity date is less than or equal to the current date.

Another way to get to an activity and document it is using View Staff Activity on the Scheduling menu. Clicking on the activity in the staff calendar is the same as doing step 6 below. The rest of the lesson is the same from there.

5. Click on an Activity Date to view or modify the activities for that day.

6. Click on the Activity Status link to open the desired activity.

From the Activity, the clinician can choose to change the Staff or Patient Status to the appropriate choice. The clinician can also add any necessary documentation.

The clinician can now choose whether to add an activity “on the fly” using the Quick Add button or use the Complete The Day button to finish with the particular day.

[1] Regulated forms are forms that have been set up so that the Supervisory staff can pay close attention to whether for form has been completed.

[2] Depending on Admisistration decisions, clinical staff may need to make sure that all of their activities and forms have been completed before billing can occur.

[3] This is particularly important if the client did not attend the appointment and there is a form specifically designed for documenting a No Show appointment.

[4] The Client Record contains information about the client that is not specific to an Episode of Care or Admission. This includes demographic information, payor information, medications, etc.