Clinical Summary

Clinical Summary

Allergies

1. Click Allergies in the Clinical Summary section.

2. Select Yes or No for Medication allergies.

   1. If Yes, type in a response for ‘what are they?’

3. Select Yes or No for Food allergies.

   1. If Yes, type in a response for ‘what are they?’

4. Select Yes or No for Environmental allergies (hay fever, dust, etc.).

   1. If Yes, type in a response for ‘what are they?’

5. Type in a Pharmacy Name.

   1. If a Pharmacy Name is provided, type in the Pharmacy Location.

   2. If a Pharmacy Name is provided, type in the Pharmacy Phone Number.

6. Click the +Add button to enter the current medication information.

   1. Type the name of the Medication.

   2. Type the Dose.

   3. Type in a response for ‘How often do you take them?’

   4. Pick a date from the calendar picker for medication Start Date.

   5. Type in a response for ‘What are they for?’

   6. To add another medication, repeat step #6.

   7. To remove a medication, click the Remove button next to that entry.

7. Click the +Add button to enter the previous medication information.

   1. Only list atypical anti-psychotics from the following: Risperdal (Risperidone), Seroquel (Quetiapine), Geodon (Ziprasidone), Zyprexa (Olanzapine), Invega (Paliperidone), Saphiris (Asenipine), Clozaril (Clozapine), Abilify (Aripiprazole), Latuda (Lurasidone), Vraylar (Cariprazine), Rexulti (brexpiprazole).

   2. Type the name of the Medication.

   3. Type the Dose.

   4. Type in a response for ‘How often do you take them?’

   5. Pick a date from the calendar picker for the medication Start Date.

   6. Pick a date from the calendar picker for the medication End Date.

   7. Type in a response for ‘What are they for?’

   8. To add another previous medication, repeat step #7.

   9. To remove a medication, click the Remove button next to that entry.

8. Click Yes or No for ‘Now or in the past 6 months, have you taken any prescribed medications for emotional or behavioral symptoms?’

   1. If Yes, Select Yes or No for ‘Have the medications helped you feel better?’

      1. If Yes, type in a response for ‘In what ways have they helped?’

   2. If Yes, select Yes or No for ‘In the past 6 months have you had any bad side effects from these medications?’

      1. If Yes, type in a response for ‘What were the bad side effects?’

9. Click the +Add button to enter the over-the-counter medication information.

   1. Type the name of the Medication, herb, vitamin, or supplement.

   2. Type the Dose.

   3. Type in a response for ‘How often do you take them?’

   4. Pick a date from the calendar picker for the medication Start Date.

   5. Type in a response for ‘What are they for?’

   6. To add another over-the-counter medication, repeat step #9.

   7. To remove an over-the-counter medication, click the Remove button next to that entry.

10. Select a response from the ‘Do not have to take medicine’ – ‘Seldom take as prescribed’ for ‘Do you have trouble taking medications as prescribed?’

    1. If taking medication, select Yes or No for ‘Do you want help with this?’

11. Click the +Add button to enter other treatments (counseling, psychotherapy, OT, PT, chiropractor, acupuncture, traditional healing, other).

    1. Type in a response for other treatments.

    2. To add another treatment, repeat step #11.

    3. To remove a treatment, click the Remove button next to that entry.

12. Click Save.

Open

Medical/ Behavioral Health History

1. Click Health History in the Clinical Summary section.

2. For questions 1-76, click Past, Present, or both for ‘Condition/Behavior - Do you have or have you ever had:’.

   1. If you select Present or both Past and Present for questions 1-76, select a response from Yes – No for ‘how much are you bothered by this condition/behavior?’

   2. If you select Present, Past, or both Past and Present for questions 1-76, select Yes or No for ‘Would you like to talk about this with your provider?’

3. Select Yes or No for ‘Problems with teeth’.

4. Select Yes or No for ‘Problems with gums.

5. Select Yes or No for ‘Difficulty chewing’.

6. Select Yes or No for ‘Difficulty swallowing.

7. Select Yes or No for ‘Appetite change last six months’.

8. Select Yes or No for ‘Weight loss’.

9. Select Yes or No for ‘Weight gain’

10. If the client is male:

    1. Select Yes or No for ‘Penis discharge’.

    2. Select Yes or No for ‘Sore on penis’.

    3. Select Yes or No for Erectile dysfunction.

    4. Select Yes or No for ‘Testicular lump’.

    5. Select Yes or No for Vasectomy.

    6. Select Yes or No for PSA.

       1. If Yes, select a date for the PSA from the calendar picker.

    7. Select Yes or No for ‘Prostate problems’.

    8. Select Yes or No for ‘Prostate exam’.

       1. If Yes, select a date for the exam from the calendar picker.

    9. Click Save.

11. If the client is female:

    1. Enter a number for ‘Period started at age:’

    2. Enter a number for ‘Number of pregnancies:’

    3. Enter a number of ‘Number of live births:’

    4. Enter a number for ‘Number of miscarriages:’

    5. Select Yes or No for ‘Birth Control’

       1. If yes, specify which birth control.

    6. Select Yes or No if the client has had a ‘Hysterectomy'

    7. Select Yes or No if the client has had a 'PAP'.

       1. If Yes, indicate the date of the last PAP smear.

    8. Select Yes or No if the client has had a ‘Mammogram.’

       1. If Yes, indicate the date of the last mammogram.

Open

E.R. Visits

1. Click E.R. Visits in the Clinical Summary section.

2. Click the teal +Add button to enter an E.R. Visit.

   1. Select a Month/Year from the calendar picker.

   2. Type in a Reason for the E.R. Visit.

   3. To add another E.R. Visit, repeat step #2.

   4. To remove an E.R. Visit, click Remove next to that entry.

3. Click Save.

Surgeries

1. Click Surgeries in the Clinical Summary section.

2. Click the teal +Add button to enter a Surgery.

   1. Select a Month/Year from the calendar picker.

   2. Type in a Reason for the Surgery.

   3. To add another Surgery, repeat step #2.

   4. To remove a Surgery, click Remove next to that entry.

3. Click Save.

Substance Abuse Treatments

1. Click Substance Abuse Treatments in the Clinical Summary section.

2. Click the teal +Add button to enter a Substance Abuse Treatment.

   1. Select a Month/Year from the calendar picker.

   2. Type in a Reason for the Substance Abuse Treatment.

   3. To add another Substance Abuse Treatment, repeat step #2.

   4. To remove a Substance Abuse Treatment, click Remove next to that entry.

3. Click Save.

Immunizations

1. Click Immunizations in the Clinical Summary section.

2. Select Yes or No for ‘Up to date?’.  Select ‘Don’t know/Not sure’ or ‘Refused’ if appropriate.

3. Select Yes or No for ‘During the past 12 months have you had either a flu shot or a flu vaccine that was sprayed into your nose?’.  Select ‘Don’t know/Not sure’ or ‘Refused’ if appropriate.

4. Select Yes or No for ‘A pneumonia shot or pneumococcal vaccine is usually given only once or twice in a person’s lifetime and is different from the flu shot. Have you ever had a pneumonia shot?’.  Select ‘Don’t know/Not sure’ or ‘Refused’ if appropriate.

5. Select Yes or No for Chicken Pox.  Select ‘Don’t Know/Not Sure’ or ‘Within last 10 years’ if appropriate.

6. Select Yes or No for DTaP (Diptheria, tetanus, acellular pertussis; 5 doses at 2, 4 6, 15 -18 mo & 4-6 yrs; <7 yrs).  Select ‘Don’t Know/Not Sure’ or ‘Within last 10 years’ if appropriate.

7. Select Yes or No for Influenza (annual dose beginning at 6 mos).  Select ‘Don’t Know/Not Sure’ or ‘Within last 10 years’ if appropriate.

8. Select Yes or No for Hepatitis A (2 doses; and 18-23 mos).  Select ‘Don’t Know/Not Sure’ or ‘Within last 10 years’ if appropriate.

9. Select Yes or No for Hepatitis B (3 doses, birth, 1 to 2 mo & 6 to 18 mos).  Select ‘Don’t Know/Not Sure’ or ‘Within last 10 years’ if appropriate.

10. Select Yes or No for Hib (Haemophilus influenza type b; 4 doses at 2, 4, 12, or 15 mos).  Select ‘Don’t Know/Not Sure’ or ‘Within last 10 years’ if appropriate.

11. Select Yes or No for HPV (Human Papilloma Virus; ages 11 to 26 females; ages 11 to 21 males).  Select ‘Don’t Know/Not Sure’ or ‘Within last 10 years’ if appropriate.

12. Select Yes or No for IPV (Inactivated poliovirus; 4 doses ; 2, 4, 6 -18 mos & 4-6 yrs; <18 yrs).  Select ‘Don’t Know/Not Sure’ or ‘Within last 10 years’ if appropriate.

13. Select Yes or No for MMR (measles, mumps rubella; 2 doses 12-15 mos & 4-6 yrs).  Select ‘Don’t Know/Not Sure’ or ‘Within last 10 years’ if appropriate.

14. Select Yes or No for Meningococcal (2 doses; 11-12 yrs and booster 16-18 yrs).  Select ‘Don’t Know/Not Sure’ or ‘Within last 10 years’ if appropriate.

15. Select Yes or No for PCV13 (Pneumococcal conjugate; 4 doses at 2, 4, 6, 12, or 15 mos).  Select ‘Don’t Know/Not Sure’ or ‘Within last 10 years’ if appropriate.

16. Select Yes or No for Shingles.  Select ‘Don’t Know/Not Sure’ or ‘Within last 10 years’ if appropriate.

17. Select Yes or No for Td/Tdap (Tetanus, diphtheria, pertussis; 11 to 12 yrs; 10 yr boosters).  Select ‘Don’t Know/Not Sure’ or ‘Within last 10 years’ if appropriate.

18. Click Save.

Hospitalizations

1. Click Hospitalizations in the Clinical Summary section.

2. Click the teal +Add button to enter a Medical/Psychiatric Hospitalization

   1. Select a Month/Year from the calendar picker.

   2. Type in a Reason for the Hospitalization.

   3. To add another Hospitalization, repeat step #2.

   4. To remove a Hospitalization, click Remove next to that entry.

3. Click Save.

Health Concerns

1. Click Health Concerns in the Clinical Summary section.

2. Select Yes or No for ‘Accident or injury prevention’.

3. Select Yes or No for ‘Ear, eye or mouth care’.

4. Select Yes or No for ‘Exercise and nutrition'.

5. Select Yes or No for ‘Health screening tests’.

6. Select Yes or No for ‘Money, housing case management’.

7. Select Yes or No for ‘Living will, end-of-life issues’.

8. Select Yes or No for ‘Long term care needs’.

9. Select Yes or No for ‘Family or personal problems’.

10. Select Yes or No for ‘Depression or other mental concerns’.

11. Select Yes or No for ‘Preventing cancer’.

12. Select Yes or No for ‘Preventing heart disease’.

13. Select Yes or No for ‘Problems with my healthcare’.

14. Select Yes or No for Other.

Care Plan Consent

1. Click Care Plan Consent in the Clinical Summary section.

2. A history of signatures is displayed at the top of the questionnaire. If no signatures have been provided, there will be nothing in the Member and/or Guardian Consent – History section.

3. Type in a Member and/or Guardian Name. This will serve as the Member and/or Guardian’s signature.

4. Select a date from the calendar picker for the Member and/or Guardian.

5. Type in a Care Coordinator Name. This will serve as the Care Coordinator’s signature.

6. Select a date from the calendar picker for the Care Coordinator.

7. Select Acknowledged.

8. Click Save.

   1. The most recent set of signatures will appear on the client’s Care Plan. This can be seen by clicking the blue ‘View Care Plan’ button in the Clinical Summary section.

View Care Plan

1. Click the blue ‘View Care Plan’ button in the Clinical Summary section.

   1. The client’s care plan is displayed. Information from several of the questionnaires can be seen here, including the electronic signatures provided in the Care Plan Consent questionnaire.

View CNA

1. Click the ‘View CNA’ button from the Clinical Summary section.

   1. The client’s entire CNA is displayed. Information from all the questionnaires can be seen here. The CNA is formatted to be printer-friendly.