Back to overview table

Computer-assisted Assessments (Intakes) and Treatment Plans

A confidential Treatment Records area of the program contains an integrated set of panels, labeled as follows:
From these several panels and their several pop-down list boxes, virtually every clinical note, intake, progress record, and termination report can be constructed.

When preparing an intake report, the therapist or support staff personnel need only select items from pop-down lists for such categories as presenting problem, mental status, family of origin history, etc. and type or dicatate additional information regarding other aspects of the case not covered by these lists (details given below). With a little practice, a completely comprehensive intake report can be generated in 10 minutes or less! Features including wnl (within normal limits) buttons make it even faster to describe more typical cases. GoalMinder constructs a comprehensive intake report, complete with demographic information, mental status information,  an analysis of the rating scales used, and a treatment plan, since the program gathers information from different areas and generates full sentences or bulleted lists from information obtained from list box selections. The data are always available for review and editing at later times. A separate panel on this therapy screen holds all treatment notes for the patient, and a handy date window gives an appointment time and date history. In addition, the date/time window identifies which sessions still need notes entered. Therapists can review the information from the therapy area prior to a patient's appointment, which quickly prepares them for the patient's session. Used remotely by on-call staff, the information is invaluable in helping patients who would otherwise not be known to the on-call practitioner. In version 4, GoalMinder provides a way to have multiple assessment templates, all user-defined, to be chosen, so that the user has a variety of different intakes or assessments to choose from.

Detailed explanation of producting an intake

The intake panel

After pressing "Treatment Records" on the main screen, Press on the Assessment tab (The leftmost tab displayed). Use the find button to bring up a client of your choice, or use the list button to bring up the names of the clients you will be treating today.

Notice that there is a set of "section heading" buttons in the middle of the form with labels such as "Explain", "Problem", etc. Pressing a button controls the contents of an interactive list box (bottom left) displaying the items associated with this section of the intake report. These headings are user-definable and can be anything you wish. A default intake typically has headings such as these:
Writing the basic intake consists of selecting a heading and then double-clicking on those items you wish to list for your client. For "Presenting problems", for example, do this:
  1. Press the "Problems"button.
  2. Notice that a list of items is listed below it in a scrolling list box. You have a choice of viewing "common" items or a fuller list of "all" items. Scroll through and as you see items that characterize the presenting problem, double-click on that item. That item then automatically appears in another box on the right side of the panel to show you which selection(s) you have made. To avoid scrolling through long lists, you can click once on any item to activate the window and then type the first letter of an item to move directly to it before double-clicking it. You can also press the wnl button to get the "typical" set of items that would be displayed if the client had no issues for that topic heading. You can then edit the list and modify just those items needed, speeding up the process tremendously.
  3. There is a large text box near the bottom right of the form labeled "Additional notes on presenting problems." If you click in there, you can write (or dictate, provided you have Dragon or comparable software) anything you like to give more detailed and personalized information about the presenting complaints of this patient. Use any format or organization you choose in this text box, and type as much or as little as you need. Notice that the text box becomes a scrolling field if you need the room. This occurs automatically to accommodate your space needs.

Why two methods of entry?

When you are selecting items from the lists provided to be included as descriptions of a patient, you are not only using a rapid method of compiling your intake report, you are also keywording your client's information. A powerful analytic tool, the aggregate analyzer can use any item selected from the Intake panel for any heading to sort or aggregate clients for later clinic-wide analyses. It is therefore important to maintain good communication among staff so that items are unambiguous and are being assigned to patients using the same criteria. This is why most clinics allow only a GoalMinder Administrator to add, subtract, or re-phrase items contained in these lists. Recall that all lists can be modified or completely replaced in GoalMinder. If you need items not displayed, or if you have different needs than those reflected in the pre-loaded lists, then change them!

Client Goals

  1. Select the "Client Goal" category from the drop-down list box.
  2. Click once in the text box that appears below the headings drop-down list box.
  3. Type in one to as many goals (using short phrases) as you wish to characterize what this client wishes to accomplish in therapy with you, putting each goal on a separate line (use return key).
  4. When you have the goals entered, press the Add button, and these goals will be shown in the right hand box. They will also be instantly available for entering data and graphing in the GoalMinder Survey Panel (see later section of this chapter). Don't forget to press the Add button or your work will not be recorded!

Family of Origin and Childhood History

Entries for this section of the intake work precisely as the Presenting Problems section, explained above. Select the heading from the drop-down list box, and then double-click on items that describe your client. Type or dictate specific details about family of origin and childhood in the "Additional information" field. There are a few conventions to notice. Some items are headed as "Biol parent(s):" The same items are found later under the item heading "Rearing parent(s):"If your patient is adopted or was raised by someone other than his/her biologic parents, then use "Rearing parent(s):" categories. If referring to biological parent characteristics, then use the Biological parent items. You don't need entries for both unless two sets of parents were involved in rearing the patient. As with all lists provided, you can use as many or as few items as you choose. Make sure you and your colleagues are using the same criteria for applying these categories to descriptions of your clients.

Drug and Alcohol Issues

This section works the same way as Presenting Problems and Family of Origin entries. Use items which best describe your client. Add to or modify the list if it doesn't suit your purposes, but do this in consultation with the rest of your colleagues, so you will all be using the same categories.

Physical Health

This section works as the above headings, using lists of items and the Additional information text box. However, when the intake report is generated, GoalMinder includes paragraphs it derives from entries in the medications and laboratory panels, respectively. Therefore, you will want to use those panels to enter data regarding medications or lab results. You won't see the fully compiled report until you select the menu item under Reports called "Intake." Make sure you read about the "Medication" Panel and the "Laboratory" Panel in later sections of this chapter.

Mental Status

As above. We've provided an extensive list of mental status items. You certainly don't need to use items from each category. Use the additional field for more specific narrative information if needed. Recall that if you have administered testing at intake or within three weeks of intake and if you summarize those results in the "Laboratory" panel, that information will be automatically incorporated into the Intake report.

Current Circumstances

This section works as most of the other intake categories. The list for this category has some basic items regarding current living arrangements, current financial circumstances, etc. You may add to this list or modify it in any way you like. You can also use the "Additional information" field to explain anything pertinent to your client's current situation or circumstances that would be relevant for his/her therapy.

Diagnosis

While listed as a heading in the drop-down heading list, diagnostic information is actually entered from the diagnosis panel of the treatment records area. See a subsequent section for use of the diagnosis panel. As with medications and lab results, the diagnosis is incorporated into the intake, but you won't see it on the screen until you select the Intake menu item under Reports.

Prior Mental Health Services

This section works the same as Presenting problems, Mental status, etc. Use the "Additional information" text area to specify names of therapists or other specific comments. Recall that the Intake report will automatically include a sentence identifying the referring individual and his/her professional title and affiliation if that information has been recorded in the Client Registration form.

Other Information

There are no items to select here. Instead, you can type or dictate any other information you choose. Click into the field and begin typing or using a voice dictation program. You can write headings within the Other field to clarify your entries. Use this area to explain or give any other information you need to finish a comprehensive report, and consider the field to act like your own word processor. If you need lots of space, the box will automatically convert to a scrolling field.

Treatment plan

This section lets you select from a comprehensive list, giving not only treatment modalities, but also ancillary recommendations (e.g., exercise program, AA, etc.) and frequency and duration parameters for recommended number of therapy appointments to have. Again, there is an "additional information" space where details can be described. A typical treatment plan might look like this:
Duration: 6 to 10 sessions
Frequency: 2 X month
Mode individual
Modality:cognitive-behavioral
relaxation training
Ancillary recommendation: Assertiveness group

Compiling, printing and finalizing your intake

Once you have entered information in relevant fields, you can read your report on the screen or print out a draft. To construct the report, do this:
  1. From any panel within the Treatment Records form, select "Intake" from the Reports menu.
  2. In a few seconds, you will see a formatted report on screen which has taken information found in the Preferences form, the Client registration form, the diagnosis, medication, laboratory, and GoalMinder surveys panels as well as from all of your entries on the Intake panel, to construct your report. The date of the report is always assumed to be the day of the initial appointment. Look over the report to see if all relevant information is present. If you notice, for example, that you don't have an occupation or a referral source indicated, then just go to the Client registration form (use the menu item "personal data" found in the Clients menu), and SAVE the information, and then return to the Session Records form to call up the Intake report again by re-selecting Intake from the Reports menu. Similarly, if you forgot to enter a diagnosis, medication, etc., do it and then re-generate the report.
  3. You can print out a draft of your formatted report by choosing the "print" item from the File menu on the preview screen of your report. Before printing, a dialog box will appear allowing you to set printer preferences. This is a standard Windows95/98/NT dialog box.
  4. When you are ready to commit to a final version of the report, first click the Finalize button on the intake panel for your client, and you will then irreversibly "lock" your intake panel entries so that they become part of a permanent record. This is like electronically signing your report. It means that you can't come back later and alter the report any more. This is a requirement of electronic medical records procedures.

The Treatment Goals Report

If you have filled out Personal Goals and Treatment Plan on the intake panel, then when you select Treatment Goals from the Reports menu, a one-page listing of the client's therapy goals and the modes of therapy planned to attain those goals will be printed, together with signature lines for the client and for the therapist. A copy can be given to the client and the report is typically kept in the client's chart. Many states have requirements for a client to agree in writing to treatment goals and to have the treatment plan clearly identified. This report usually satisfies that requirement.
return to summary feature table