Efficiently Documenting Assessments and Care Plans Together 

This guide provides step-by-step instructions for managing assessments and updating care plans simultaneously, ensuring accurate and comprehensive records for clients. 


1. Access the Client and Assessment

  1. Navigate to the Client Profile.
  2. Select the appropriate Assessment to begin.

2. Identify Needs

  • Review the assessment questions to identify those linked to client needs.

3. Open the Care Plan

  1. Unlock the assessment to make changes.
  2. Select Care Plan to open it in a separate window.

4. View the Care Plan Details

  • Use the Expand All option to display all details within the Care Plan.

5. Check the Assessment Activity Date

  • Confirm the Activity Date in the assessment to ensure actions align correctly.

6. Review Related Details

  • In the Care Plan, review:
    • Assessment Memos
    • Identified Needs
    • Resources

7. Viewing and Managing the Care Plan

Updating the Care Plan

  • Review the Care Plan and locate the Problem/Need to update.

Adding Actions and Follow-Ups

  1. Select a Resource and click the New Action icon.
  2. Choose the desired action and confirm that the action is linked to the correct assessment activity.
  3. Click Add to save the action.

Adding Notes for Non-TCM Needs

  1. Click the New Memo icon to add notes.
  2. The memo automatically links to the current assessment activity and displays the activity date.

8. Finalizing Updates

  • Continue working on your assessment while referring to or updating the Care Plan.

Cautionary Notes

  • Select the Correct Assessment and Date: Ensure new actions are associated with the correct assessment and date.
  • Avoid Data Loss: Double-check details before editing or deleting actions and resources.
  • Accuracy is Key: Mistakes in Care Plan updates can affect client care continuity.

Tips for Efficiency

  • Dual Windows: Keep the Care Plan and Assessment open in separate windows for easy navigation.
  • Expand All Feature: Use this feature in the Care Plan to view all details without extra clicks.
  • Edit Icon: Utilize the edit feature to track the history of actions and resources for better accountability.

By using dual tabs, you can streamline your workflow by documenting assessments and updating care plans simultaneously. This ensures that care plans reflect the latest assessment data, improving efficiency and accuracy.