To initiate the BioPsychoSocial Intake on a prospective client go to the navigational menu on the left side of the screen and select the "Prospective" section and then the "Prospective Client List" subsection. Once there select the person icon under the 'Actions' column that corresponds to client of interest.
-A green circle indicates that the document is signed off and completed.
To initiate the BioPsychoSocial Intake on an active client, go to the facesheet of the chart and select the BPS from the "Client Overview" section.
You can input the date and the time of the Intake. Select the first boxes under the words "Start Time" and "End Time" and a calendar will appear for you to input the date. The time auto-fills to when you open the document.
You also have the option of adding to 'Diagnosis/Problems'. Here you can add multiple diagnosis/ problems to the Intake by selecting from the Problem Group (which is Addiction 5E ALWAYS NO MATTER WHAT!!!!!); then select the "Problem Name" from the drop-down menu; and then select the "ICD-10/DSM-5 Code". Check the "Is Primary" box if that is the client's primary diagnosis and then click "Save" when you're done. The information will be added to the list below and you can add more diagnosis and problems by following the same steps above.
Next is the "Substance Abuse" section. Here you can add the substance used, client's history, last used, amount used, and other information.
To add the substance just type in the name of the drug or substance or choose one from our drop-down menu. If you don't see the substance that the client has abused you can add a new one by typing in the name of the drug and clicking the "+" icon on the right side of the "Primary Substance Used" box.
Next fill in all the other known information and select "Save" when done.
After pressing "Save" the information will be added to the queue. If you would like to add more than one substance just repeat the above steps and more will be added to the queue.
The next section is "Family Information". Here you can add all known information about the client's family. Either type in the known information or select either "Yes" or "No" to the following questions. When you are finish click "Save".
When you are finished the page will appear like this. The red "X" DOESN'T mean something is wrong, but just that it was either a "No" or an unanswered question. If you would like to edit any information just select the "Edit" icon on the top right-hand corner of the section.
7. The next eleven sections of the BioPsychoSocial Intake are very similar in that all you need to do is fill in all known information by either typing in the information or checking the correct boxes. Select "Save" when you have filled in all known information. Follow these instructions for the sections entitled "Psychocoial History", "Suicide Screen", Family History", "Vocational Screen", "SNAP", "Physical Pain", "Emotional Pain", "Gender/Sexual Orientation & Sexual Functioning", "Spiritual/ Religious Assessment", "Culture", and "Nutritional Self Assessment".
8. The "American Society of Addiction Medicine (ASAM) Dimensions" section is a place to fill out any known information about the prospective client's current condition and information vital to their current and future treatment. To add any information just select the box that has information relating to the prospective client or fill in the boxes by typing in your answer.
Follow the same instructions for the following sections: "2. Conditions/Complaints", "3. Emotional/ Behavioral/ Cognitive Conditions/ Complications", "4. Treatment Acceptance/ Resistance", "5. Relapse/ Continued use/ Continued Problem Potential", and "6. Recovery Environment".
Select "Save" when you are finished filling out all known information.
If you would like to go back an edit any existing information just select the "Edit" icon; which is located on the top right-hand side of each section.
9. In the "Other" section of this page you can enter in all known information about 'High Risk Behaviors', 'Safety Plans', 'Preliminary Plans', 'Diagnosis & Integrative Summary, recommended care, 'Mental Health History and Current Symptoms' and lastly 'Reasons for Seeking Treatment'. Answer the questions by checking the boxes or typing in the correct information.
Once you have completed filling in all known information select "Save". To edit any existing information select the "Edit" icon on the top right-hand corner of the section.
10. The last section of the BioPsychoSocial Page is the "Consent Forms". Start by selecting which forms you want the prospective client to review, sign and complete by clicking "ADD CONSENT FORM".
Then this pop-up screen will appear allowing you to choose which form to add to the queue. Select which forms you would like the prospective client to complete by clicking on the "ADD" button on the correct forms.
Next, submit the form by clicking on the "Form Name" of the consent form.
Then this screen will appear for the prospective client to read and approve. When the client is ready to submit the form just click on "Submit" in the bottom right-hand corner of the screen.
You can add a description or notes if you want by selecting the "click here to add description"
The next step is to have the client input their electronic signature. To do this select the "Click here to sign" option under the 'Prospective Client Signature' column.
This page will then populate allowing the prospective client to sign their name. Follow the instructions on the page to submit the signature by clicking the "Click here after signature" button.
Next, the staff completely the intake will need to sign off on the consent form. To do this, select the "click here to sign" under the 'Office Signature" column and follow the same steps for the prospective client's signature. The office staff completeing the intake form can either enter their "Pin" or add their own signature. Select "Click here after signature" when you are done.
The "Consent Form" section has some icons that can preform different tasks. For example, once you have selected a specific form, you can select the "Printer Icon" which will allow you to print the selected consent form. The paper and pen icon will allow you to change or update the staff's signature on the selected form. And the "eye" icon under the Actions column will allow you to view the completed document with your treatment center's logo, time, signatures, and other information.
11. Once you have completed all of the sections with all known information select the "Save & Assign" button at the very bottom of the page. This screen will appear asking for one last signature from the staff completing the intake. After you have entered in the your "Pin" or signed your name add any notes that contain necessary information for this intake.
When you have completed this form the icon on the main "Prospective Client" Page the BioPyschoSocial Intake icon will turn green (meaning that it is completed).