Overview of documentation at Rula

AdvancedMD offers a range of documentation templates designed to streamline your clinical workflow. This article provides an overview of these templates, focusing on their accessibility and categorization, to enhance your experience with initial assessments, progress notes, and other clinical documentation needs.

Video Overview

Note: We're now Rula! You may still hear Path in our videos from time to time and we appreciate your patience while we continue to update our content to align with our new name.

This video provides an overview of utilizing documentation templates in AdvancedMD.

Accessing Documentation Templates

To access a new initial assessment or progress note in AdvancedMD, simply double-click on the appointment from your dashboard. This action will open the client’s chart and automatically create a new note for you. To view all available templates, navigate to the note template page and use the drop-down menu next to the templates field.

Categories of Templates: Billable and Non-Billable

Documentation templates in AdvancedMD are divided into two main categories: billable and non-billable.

Billable Notes

  • Initial Assessment and Treatment Plan Template: This is crucial for your first meeting with a new client. It consists of six tabs, including History, Child/Adolescent (for minors), Risk Assessment, Mental Status Exam (MSE), Summary, and Treatment Plan.
  • Progress Note Formats: There are two formats available, each with three tabs: the progress note, a risk assessment, and the treatment plan. Changes made to the treatment plan will be reflected in future progress notes with that client.

Each billable note, available in individual and couples/family versions, will automatically generate a charge slip once signed. Required fields in these templates are highlighted in yellow and must be completed before signing the note.

Non-Billable Notes

  • Discharge Note: Used to indicate a client’s discharge from care or service termination. It's important to note that a progress note is still required for the client's last appointment, despite the non-billable nature of the discharge note.
  • Blank Note: This flexible template can be used as an addendum to a signed note or for documenting any non-billable information.
  • Safety Plan: This template is essential for clients assessed as medium or high risk. It assists in creating and documenting a safety plan collaboratively with the client during a session.

Importance of Proper Documentation

Proper use of these templates not only ensures compliance with clinical documentation standards but also enhances the quality of care provided to clients. Familiarity with these templates and their appropriate usage is key to maximizing the benefits of AdvancedMD’s features for your clinical practice.

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