Problems, Objectives, and Interventions, by default, can be entered in the following notes and treatment reports: Intake Note Other Sections, Progress Note Optional Sections, Outpatient Treatment Plan Other Sections, Inpatient Treatment Plan, and Discharge Note. You can also set it up to appear in any note or report.
There are three sub-sections:
| • | Problems: Identify the problem. |
| • | Goals/Objectives: Enter goals and objectives for the problem. |
| • | Interventions: Enter interventions you will use. |
To Add a Problem
| 1. | Click the blue underlined text 'Add a Problem.' |
| 2. | Click the down arrow for a pick list of problems to enter a problem in the Problem field, or type in the field. |
| 3. | Enter a qualifier, if applicable, in the As Evidenced by field. |
| 4. | Enter the Date Identified. |
| 5. | Use drop down pick lists to enter a Severity rating and the Status. |
| 6. | Click OK. |
Edit a Problem: Select the problem from list and click 'Edit Selected Problem,' or double-click on the problem.
Delete a Problem: Select the problem from the list and press the Delete key, or drag and drop into the trashcan.
NOTE: All related goals, objectives, and interventions will be deleted.
Goals/Objectives
Goals
Click the button for Goals/Objectives. The Problem you selected will be displayed in the field at the top of screen.
Goal: Enter a general statement for the goal, a target date, and evidence of the goal's achievement.
For Progress Notes, you can record a percentage of progress achieved.
Use the Delete key to delete text in goals fields.
Objectives
Enter an objective for the problem. Select from the drop down list, or type in the field. Click Ok to save.
To delete, select the objective and press the Delete key, or drag and drop into trashcan.
Interventions
Click the button for Interventions. The Problem entered or selected is displayed in the field at the top of screen. Enter an Intervention for the problem. Select it from the drop down list, or type in the field.
Enter Frequency and Staff Responsible. Click Ok to save.
To delete, select the Intervention and press the Delete key, or drag and drop into the trashcan.
See Also