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LCSW- How to document for this Provider

CPS, C-EMR, PM

Last Post by Anonymous 1 second ago

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guilfordmedical

(@guilfordmedical)

Posts: 203

Reputable Member

Topic starter

We are an Internal Medicine Practice and we have just hired a Licensed Clinical Social Worker (LCSW), expected to start in June. If you have Behavioral Health on staff, how do you document the visit in CPS and what is documented (free text, obs term, etc.)? Are we required to make patients "sensitive"?

Any feedback or advice would be VERY helpful!

Thanks in advance!
Ashley

Posted : April 12, 2017 8:48 am

Pamela Bender

(@pboffemmyer)

Posts: 57

Trusted Member

We have LCSW staff in our clinics and have created encounters for initial and follow-up visits. I would be happy to share our clinical kits with you if you would like to view them.

As an organization, we decided to not mark our BH patients as sensitive, but each organization has different views about this.

If you are interested in the clinical kits, please send an email: [email protected]

Thank you.

Posted : April 12, 2017 10:32 am

joeg1962

(@joeg1962)

Posts: 843

Noble Member

We at Tufts also have social workers. We do not mark patients as sensitive, however we have created a few new encounter documents - a couple that are general, and a couple that are 'confidential documents' that only the social workers can view and one that the social workers and doctors can see.

We used a couple of test/dummy patients to test out all the settings, but all seems to now be working well.

Most of the data is free text, although a few codes (OBS) may be set in any of the encounters.

Be happy to talk more, if you wish.

Joe Gillis

Tufts Medical Center, Primary Care

Posted : April 13, 2017 12:36 am

jessicaw

(@jessicaw)

Posts: 434

Prominent Member

We have a couple of Behavioral Health Specialist in our Clinic and we do not mark the patients as sensitive. We do however have a document type that they use for their office visits with a confidentiality setting only the Behavioral Health providers, billers and myself can see. We also have a confidentiality type for Mental health documents that are imported (such as outside records) that All providers, billers and myself can see. We have been on CPS for 2 years and up to this point the BH providers have been using Text components to complete their dictation but we are in the process of trying to find forms to assist them with documentation.

Posted : April 13, 2017 3:11 am

mkriesch

(@mkriesch)

Posts: 6

Active Member

We have customized all of our documents for behavioral health . We do not use the sensitive chart feature. However, we have them set up as a separate location of care and the documents are confidential.

Posted : October 26, 2017 6:42 pm

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