Recording Substance Abuse and Positive Infant Toxicology Person Characteristic Records

Transcription

1 Recording Substance Abuse and Positive Infant Toxicology Knowledge Base Article

2 Table of Contents Overview... 3 Navigating to the Person Characteristic Fields... 3 Important Definitions... 5 Adding a Characteristic... 6 Recording Characteristics within a Medical Treatment Record Marking a Characteristic as Created in Error Page 2 of 13 Last Revised: 03/23/2016

3 Overview This article describes how to add Characteristics to a Person Profile for documenting a parent or older child s Substance Abuse issues, and for documenting an infant s Prenatal Exposure. Characteristics added to document a parent or older child s substance abuse issues are added in the Mental Health/Substance Abuse Characteristic Group. Characteristics added to document an infant s prenatal exposure are added in the Prenatal/Birth Characteristic Group. The characteristics may be recorded as Clinically Diagnosed by a doctor or clinician, Observed, or Self-Reported by the parent or another person. Navigating to the Person Characteristic Fields 1. To navigate to the Person Profile, click the Search button on the SACWIS Home screen. The Person Search Criteria screen (Person Search tab) appears as shown on the next page. Page 3 of 13 Last Revised: 03/23/2016

4 2. Enter search information into the fields OR enter the Person ID number, if known. 3. Click the Search button at the bottom of the screen. The results appear in the Person Search Results grid at the bottom of the screen. 4. Click the Edit link beside the appropriate Person ID. The Person Profile appears displaying the Basic tab. 5. Click the Characteristics tab. Page 4 of 13 Last Revised: 03/23/2016

5 The Documented Person Characteristics screen appears. Important Definitions Clinically Diagnosed characteristics include any medical, physical, or mental health condition which has been diagnosed by a Qualified Professional. Documentation of the person s Clinically Diagnosed condition must be maintained in the child s Case record. Otherwise, the condition may be documented as Self-Reported or Observed. Example: If the parent reports that the older child has been using amphetamines, this can be added by selecting Self-Reported in the Method field, instead of Clinically Diagnosed. (This is discussed further below.) Page 5 of 13 Last Revised: 03/23/2016

6 Adding a Characteristic Follow the steps below to add a characteristic on the Documented Person Characteristics screen for documenting a parent or older child s substance abuse issues or an infant s prenatal exposure. 1. In the Characteristic Type field, select the appropriate characteristic type from the drop-down list: Mental Health/Substance Abuse for documenting a parent or older child s substance abuse issues. Prenatal/Birth for documenting an infant s prenatal exposure. 2. Click the Add Characteristic button. The Characteristics Details screen appears for the selected characteristic type. Page 6 of 13 Last Revised: 03/23/2016

7 Important: Each Substance Abuse characteristic has an Involved/Abuse characteristic and an Addiction/Dependence characteristic. For example, you will see Opiate- Involved/Abuse and Opiate-Addiction/Dependence as shown in green below. The Involved/Abuse characteristic should be selected when the client is not acknowledging an addiction or dependence but substance use is reported and a formal addiction or dependence diagnosis has not yet been made. The Addiction/Dependence characteristic should be selected when the client acknowledges that they are addicted or dependent on a substance, or a formal addiction or dependence diagnosis has been made. 3. In the Available Characteristics list, select the applicable characteristic. 4. Click the Add link to move the choice to the Selected Characteristics list. Note: You can select a characteristic in the Selected Characteristics list and click the Remove link to move the characteristic back to the Available Characteristics list. 5. Repeat Steps 3-4 for each characteristic you wish to add to the Selected Characteristics list. Page 7 of 13 Last Revised: 03/23/2016

8 6. In the Method field, click the appropriate radio button. If you select the Self-Reported, Observed, or Clinically Diagnosed radio button in the Method field, additional fields appear. Note: The names of the additional fields change depending on the radio button selected in the Method field, as shown in the screens below. The field names referenced in Steps 7-8 below apply for the Clinically Diagnosed option. 7. In the Diagnosed By field, enter the name of the qualified professional or the name of the Clinic or Doctors office who diagnosed the person. 8. Enter a date in the Diagnosis Date field. (Required) Page 8 of 13 Last Revised: 03/23/2016

9 9. Enter narrative in the Additional Information text box, if applicable. (Optional) 10. Click the Save button at the bottom of the screen. The Documented Person Characteristics screen appears displaying the selected characteristic(s) in the Person Characteristics grid. 11. If you locate a record without a Begin Date, click the Edit link in that grid row to add the date for that condition. Important: Prior versions of SACWIS did not require that a Begin Date be entered, but the date is now required for Self-Reported, Observed, and Clinically Diagnosed methods. Page 9 of 13 Last Revised: 03/23/2016

10 Recording Characteristics within a Medical Treatment Record Clinically Diagnosed characteristics may also be recorded from within a Medical Treatment record (Person Profile > Medical link > Treatment tab > Add Treatment button). The Treatment Details screen displays a Currently Diagnosed Characteristics grid (shown in red below). 1. In the Add Characteristics field, select the appropriate characteristic type from the drop-down list: Mental Health/Substance Abuse for documenting a parent or older child s substance abuse issues. Prenatal/Birth for documenting an infant s prenatal exposure. Note: Medical or Mental Health/Substance Abuse will be pre-populated based on the Treatment Type selected (shown in green above). Select a different Characteristic Type if appropriate. 2. Click the Add Characteristics button. Page 10 of 13 Last Revised: 03/23/2016

11 The Characteristics Details screen appears. Note: As shown in green below, the Method of Clinically Diagnosed is pre-selected, and the Diagnosed By and Diagnosed Date fields are pre-populated with the Provider and Date information from the Treatment Details record. You may change these fields if needed. 3. Complete the fields on the screen as usual. 4. Click the Save button. The Treatment Details record appears displaying the newly added Characteristic. Page 11 of 13 Last Revised: 03/23/2016

12 Marking a Characteristic as Created in Error Follow the steps below if a characteristic was selected in error. 1. In the Person Characteristics grid on the Documented Person Characteristics screen, click the Edit link beside the characteristic that was added in error. The Characteristics Details screen appears. A Created in Error check box displays near the bottom of the screen. 2. Click the Created in Error check box. 3. Click the Save button. Page 12 of 13 Last Revised: 03/23/2016

13 The Characteristics Details screen appears and no longer displays the characteristic marked as Created in Error. By default, the Person Characteristics grid is filtered to Exclude records marked as Created in Error, as shown in green below. Note: To display records marked as Created in Error, click the Include radio button above the Person Characteristics grid. If you need additional information or assistance, please contact the SACWIS Help Desk. Page 13 of 13 Last Revised: 03/23/2016