Tier Quick Reference for GIRP Notes (As of 7/30/2018)

Transcription

1 Tier Quick Reference fr GIRP Ntes (As f 7/30/2018) Effective 7/30/2018 the GIRP Nte has been restructured t include buttns fr the specific type f nte yu wish t prduce: GIRP Initial Assessment GIRP Annual Update GIRP Rehab GIRP Therapy GIRP Nte GIRP Initial Assessment T Cmplete a GIRP nte fr the Initial Assessment: 1. Click the Prgress Nte tab in the Clinician, Physician r Nursing Cnsle. 2. Search fr the client fr whm yu are writing a GIRP - Therapy prgress nte. 3. Click n client s name t highlight it. 4. Click n the GIRP - Therapy buttn. 5. Cmplete billing infrmatin n Page 1. Enter the date f service in the Date field. DCFS Invlvement: Select Yes/N t indicate if client has an pen DCFS case. If a selectin is already made, nly change it if client s DCFS status has changed. Select Department and Prgram. Select yur name, if needed. Select Prcedure Cde. Be careful t chse the crrect cde fr the frm type. Select the Service Lcatin (Clinic). Click the Bill Phne Time checkbx if yu are dcumenting a telephne call. Select the Place f Service (Office, Schl, etc.). Service lcatins ther than Office require cmpletin f the address fields. Services prvided at schl will require that yu select the name f the schl. Once the schl is selected, the address fields will aut-fill. Select a Lck Out cde, if needed. Cmplete the Face t Face and Other time fields. Select Staff 2 and 3 name and cmplete the FF/OT fields if ther staff were present. Please refer t Tier Quick Reference sheet fr Secnd/Third staff prgress nte cmpletin prcedure. 6. Click n Page 1 Gal: indicate if service was interpreted, prvided in ther than English. If either is selected, select language frm the drp-dwn. Interventin: check all bxes that apply t the sessin. Respnse: Check all bxes that apply t the sessin. If Other is selected, prvide explanatin in frm field that appears. 7. Click n Page 2. Cmplete all areas n this page Cmplete the Client presentatin, SX, BX bserved during assessment checkbxes and add cmments, as needed (Hallucinatins, Thught Disrder, Other). Check the radi buttns fr Suicidal Ideatin, Hmicidal Ideatin, and Histry f psychiatric hspitalizatins. Nte: any Yes answers will require applicable risk assessment. Page 1 f 7

2 Tier Quick Reference fr GIRP Ntes (As f 7/30/2018) Cmplete the Client reprted the fllwing Sx field. 8. Click n Page 3. Cmplete any Functinal Impairment checkbxes that apply. Cmplete the Client Diagnsis and justificatin in text bx. Cmplete the Hw d client s SX cause functinal impairments text bx. Check the This Nte Dcuments Medical Necessity checkbx, if needed. 9. Click n Page 4. Cmplete the Recmmendatins fr Treatment checkbxes that apply. If EBP is selected, select applicable EBP frm drp-dwn. Or, Select radi buttn Ntice f Actin (NOA) Prvided. If yes, prvide infrmatin in cmment bx. Check radi buttn t indicate if client/guardian/parent agrees r des nt agree t recmmended treatment. If client/guardian/parent did nt agree t recmmended treatment, cmplete the text bx that appears. Cmplete the Plan text bx. 10. Cmplete c-signature infrmatin under the C-signatures tab, if necessary. 11. The last tab is t add an addendum t a final saved dcument. 12. Click the Save buttn in the tp right crner f the screen. Select Save if yu intend t cntinue t edit the nte later. DO NOT use the Save as Draft ptin. Final Save the nte when yu have cmpleted it. Check the Final Save Entire Frm (Final Signature) checkbx. Enter yur signature passwrd, click OK. GIRP Annual Update T Cmplete a GIRP nte fr the Annual Update: 1. Click the Prgress Nte tab in the Clinician, Physician r Nursing Cnsle. 2. Search fr the client fr whm yu are writing a GIRP - Therapy prgress nte. 3. Click n client s name t highlight it. 4. Click n the GIRP - Therapy buttn. 5. Cmplete billing infrmatin n Page 1. Enter the date f service in the Date field. DCFS Invlvement: Select Yes/N t indicate if client has an pen DCFS case. If a selectin is already made, nly change it if client s DCFS status has changed. Select Department and Prgram. Select yur Name, if needed. Select Prcedure Cde. Be careful t chse the crrect cde fr the frm type yu are using. Select the Service Lcatin (Clinic). Click the Bill Phne Time checkbx if yu are dcumenting a telephne call. Select the Place f Service (Office, Schl, etc.). Service lcatins ther than Office require cmpletin f the address fields. Services prvided at schl will require that yu select the name f the schl. Once the schl is selected, the address fields will aut-fill. Page 2 f 7

3 Tier Quick Reference fr GIRP Ntes (As f 7/30/2018) Select a Lck Out cde, if needed. Cmplete the Face t Face and Other Time fields. Select Staff 2 and 3 name and cmplete the FF/OT fields if ther staff were present. Please refer t Tier Quick Reference sheet fr Secnd/Third staff prgress nte cmpletin prcedure. 6. Click n Page 1. Cmplete all areas n this page Objective: If services were interpreted, enter the language in the field that appears. Gal: Select Yes/Deferred fr Re-established Medical Necessity Check the Diagnsis changed/updated check bx and justify new diagnses in the text bx belw. Areas f impairment: check all that apply. Interventins: check all that apply. If EBP is selected, specify in drp dwn. Check the This Nte Dcuments Medical Necessity, if needed. 7. Click n Page 2. Prpsed Interventin(s): Select the applicable items n bth sides f the AND t indicate the ptential impact f the prpsed interventins. Cmpleted the fllwing: check the bx next t each item cmpleted Respnse t treatment ver the last year: Indicate in cmment bx belw. Items cmpleted that were nt billed t Medi-Cal: check bxes, if applicable. Indicate if client accepted cpy f treatment plan. Cmplete the Plan field. 8. Cmplete c-signature infrmatin under the C-signatures tab, if necessary. 9. The last tab is t add an addendum t a final saved dcument. 10. Click the Save buttn in the tp right crner f the screen. Select Save if yu intend t cntinue t edit the nte later. DO NOT use the Save as Draft ptin. Final Save the nte when yu have cmpleted it. Check the Final Save Entire Frm (Final Signature) checkbx. Enter yur signature passwrd, click OK. GIRP Rehab T Cmplete a GIRP nte fr rehab: 1. Click the Prgress Nte tab in the Clinician, Physician r Nursing Cnsle. 2. Search fr the client fr whm yu are writing a GIRP - Rehab prgress nte. 3. Click n client s name t highlight it. 4. Click n the GIRP - Rehab buttn. 5. Cmplete billing infrmatin n Page 1. Enter the date f service in the Date field. DCFS Invlvement: Select Yes/N t indicate if client has an pen DCFS case. If a selectin is already made, nly change it if client s DCFS status has changed. Select Department and Prgram. Select yur name, if needed. Select Prcedure Cde. Be careful t chse the crrect cde fr the frm type. Select the Service Lcatin (Clinic). Click the Bill Phne Time checkbx if yu are dcumenting a telephne call. Page 3 f 7

4 Tier Quick Reference fr GIRP Ntes (As f 7/30/2018) Select the Place f Service (Office, Schl, etc.). Service lcatins ther than Office require cmpletin f the address fields. Services prvided at schl will require that yu select the name f the schl. Once the schl is selected, the address fields will aut-fill. Select a Lck Out cde, if needed. Cmplete the Face t Face and Other time fields. Select Staff 2 and 3 name and cmplete the FF/OT fields if ther staff were present. Please refer t Tier Quick Reference sheet fr Secnd/Third staff prgress nte cmpletin prcedure. 6. Add Objectives frm Master Treatment Plan n the Objective tab: Click the Add Objectives frm the Master TX Plan buttn t view a list f current bjectives. Click t highlight the bjective yu want t add t yur nte. Press the Add Objective t Nte buttn at the bttm f the page. The bjective will be included in the printed prgress nte but will nt shw n the electrnic dcument. 7. Click n Page 1. Cmplete all areas n this page If services were interpreted, enter the language in the field that appears. If services were prvided in the field, cmplete the radi buttns and cmment fields that appear. Cmplete the Client presentatin, SX, BX bserved and reprted in sessin checkbxes and add cmments, as needed (Hallucinatins, Thught Disrder, Other). Check the radi buttns fr Suicidal/Hmicidal Ideatin. Nte: Any Yes answers will require applicable assessment(s). Cmplete the Client check in field. 8. Click n Page 2. Cmplete the Interventin checkbxes by checking all that apply. Cmplete the explanatin field next t Other, if applicable. Cmplete the Specify interventins and describe hw they address client s impairments/sx field. 9. Click n Page 3. Cmplete the Respnse areas: Quantifiable Statement f prgress tward gal(s) Summary f prgress, impasse, r regressin in treatment. Plan/future/treatment/fllw-up issues. Cmplete the Next scheduled sessin date field. 10. Cmplete c-signature infrmatin under the C-signatures tab, if necessary. 11. The last tab is t add an addendum t a final saved dcument. 12. Click the Save buttn in the tp right crner f the screen. Select Save if yu intend t cntinue t edit the nte later. DO NOT use the Save as Draft ptin. Final Save the nte when yu have cmpleted it. Check the Final Save Entire Frm (Final Signature) checkbx. Enter yur signature passwrd, click OK. GIRP Therapy Page 4 f 7

5 Tier Quick Reference fr GIRP Ntes (As f 7/30/2018) T Cmplete a GIRP nte fr therapy: 1. Click the Prgress Nte tab in the Clinician, Physician r Nursing Cnsle. 2. Search fr the client fr whm yu are writing a GIRP - Therapy prgress nte. 3. Click n client s name t highlight it. 4. Click n the GIRP - Therapy buttn. 5. Cmplete billing infrmatin n Page 1. Enter the date f service in the Date field. DCFS Invlvement: Select Yes/N t indicate if client has an pen DCFS case. If a selectin is already made, nly change it if client s DCFS status has changed. Select Department and Prgram. Select yur name, if needed. Select Prcedure Cde. Be careful t chse the crrect cde fr the frm type. Select the Service Lcatin (Clinic). Click the Bill Phne Time checkbx if yu are dcumenting a telephne call. Select the Place f Service (Office, Schl, etc.). Service lcatins ther than Office require cmpletin f the address fields. Services prvided at schl will require that yu select the name f the schl. Once the schl is selected, the address fields will aut-fill. Select a Lck Out cde, if needed. Cmplete the Face t Face and Other time fields. Select Staff 2 and 3 name and cmplete the FF/OT fields if ther staff were present. Please refer t Tier Quick Reference sheet fr Secnd/Third staff prgress nte cmpletin prcedure. 6. Add Objectives frm Master Treatment Plan n the Objective tab: Click the Add Objectives frm the Master TX Plan buttn t view a list f current bjectives. Click t highlight the bjective yu want t add t yur nte. Press the Add Objective t Nte buttn at the bttm f the page. The bjective will be included in the printed prgress nte but will nt shw n the electrnic dcument. 7. Click n Page 1. Cmplete all areas n this page If services were interpreted, enter the language in the field that appears. If services were prvided in the field, cmplete the radi buttns and cmment fields that appear. Cmplete the Client presentatin, SX, BX bserved and reprted in sessin checkbxes and add cmments, as needed (Hallucinatins, Thught Disrder, Other). Cmplete the Client check in field. Check the radi buttns fr Suicidal/Hmicidal Ideatin. Nte: Any Yes answers will require applicable assessment(s). 8. Click n Page 2. Check all Interventin checkbxes that apply. Cmplete the cmments fields under Other and EBP, if necessary. Cmplete the Specify interventins and describe hw they address client s impairments/sx field. 9. Click n Page 3. Cmplete the Respnse areas and Plan/Future/Fllw-up issues area. Cmplete the Next scheduled sessin date field. Check the This Nte Dcuments Medical Necessity bx, if needed. 10. Cmplete c-signature infrmatin under the C-signatures tab, if necessary. 11. The last tab is t add an addendum t a final saved dcument. Page 5 f 7

6 Tier Quick Reference fr GIRP Ntes (As f 7/30/2018) 12. Click the Save buttn in the tp right crner f the screen. Select Save if yu intend t cntinue t edit the nte later. DO NOT use the Save as Draft ptin. Final Save the nte when yu have cmpleted it. Check the Final Save Entire Frm (Final Signature) checkbx. Enter yur signature passwrd, click OK. GIRP Nte The riginal GIRP nte will still need t be used in the fllwing circumstances: Crisis Billing. Cmpleting an assessment service with the client after the initial appintment r with cllaterals and nn-client/nn-cllaterals. When cmpleting an annual service while prviding clinical rehab, therapeutic interventins, r assessment. T cmplete a GIRP nte: 1. Click the Prgress Nte tab in the Clinician, Physician r Nursing Cnsle. 2. Search fr the client fr whm yu are writing a GIRP prgress nte. 3. Click n client s name t highlight it. 4. Click n the GIRP Nte buttn. 5. Cmplete billing infrmatin n Page 1. a. Enter the date f service in the Date field. b. DCFS Invlvement: Select Yes/N t indicate if client has an pen DCFS case. If a selectin is already made, nly change it if client s DCFS status has changed. c. Select Department and Prgram. d. Select Prcedure Cde. Be careful t chse the crrect cde fr the frm type. e. Select the Service Lcatin (Clinic). f. Click the Bill Phne Time checkbx if yu are dcumenting a telephne call. g. Select the Place f Service (Office, Schl, etc.). Service lcatins ther than Office require cmpletin f the address fields. Services prvided at schl will require that yu select the name f the schl. Once the schl is selected, the address fields will aut-fill. h. Select a Lck Out cde, if needed. i. Cmplete the Face t Face and Other time fields. j. Select Staff 2 and 3 name and cmplete the FF/OT fields if ther staff were present. k. Please refer t Tier Quick Reference sheet fr Secnd/Third staff prgress nte cmpletin prcedure. 6. Add Objectives frm Master TX Plan n Page 2: a. Click the Add Objectives frm the Master TX Plan buttn t view a list f current bjectives. b. Click t highlight the bjective yu want t add t yur nte. c. Press the Add Objective t Nte buttn at the bttm f the page. d. The bjective will be included in the printed prgress nte but will nt shw n the electrnic dcument. 7. Finish cmpleting the prgress nte frm in the GIRP frmat n Page 3. a. Gal (MTP Objective): If yu added an bjective t page 2, a gal is nt required n page 3, hwever yu can add Page 6 f 7

7 Tier Quick Reference fr GIRP Ntes (As f 7/30/2018) additinal infrmatin if yu wish t. The Gal sectin f page 3 can still be used fr manually entering gals if the MTP has nt been cmpleted yet. b. Cmplete the Interventin, Respnse, and Plan fields. c. Check the This Nte Dcuments Medical Necessity bx, if applicable. 8. Cmplete c-signature infrmatin n page 4, if necessary. 9. Click the Save buttn in the tp right crner f the screen. a. Select Save if yu intend t cntinue t edit the nte later. b. DO NOT use the Save as Draft ptin. c. Final Save the nte when yu have cmpleted it. Page 7 f 7