📋 Patients & Document Status
| Patient | MRI | FIDO | Bio-Psych | FARS/CFARS | Tx Plan | Progress | Discharge | Actions |
|---|---|---|---|---|---|---|---|---|
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👥 Patient Selection
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This bilingual assessment tool is designed to assist clinicians in gathering comprehensive information about client symptoms and behaviors using the FIDO framework: Frequency, Intensity, Duration, and Onset. This structured approach helps to create a clear clinical picture for accurate diagnosis and effective treatment planning.
Esta herramienta de evaluación bilingüe está diseñada para guiar a los clínicos en la recopilación de información completa sobre los síntomas y comportamientos del cliente utilizando el marco FIDO: Frecuencia, Intensidad, Duración y Origen. Este enfoque estructurado ayuda a crear una imagen clínica clara para un diagnóstico preciso y una planificación efectiva del tratamiento.
🎙️ Record / Transcribe for FIDO Assessment
Ready🔒 Audio is processed securely via Whisper API and never stored permanently.
👤 Client Information / Información del Cliente
⚠️ Primary Concerns / Preocupaciones Principales
What are the main issues that brought you to seek help today?
¿Cuáles son los principales problemas que le llevaron a buscar ayuda hoy?
📊 F - Frequency / Frecuencia
🔥 I - Intensity / Intensidad
⏱️ D - Duration / Duración
📅 O - Onset / Origen
🔄 Contextual Factors / Factores Contextuales
What situations, thoughts, or experiences seem to trigger or worsen these symptoms?
¿Qué situaciones, pensamientos o experiencias parecen desencadenar o empeorar estos síntomas?
What helps reduce or manage these symptoms when they occur?
¿Qué ayuda a reducir o manejar estos síntomas cuando ocurren?
📉 Impact Assessment / Evaluación del Impacto
How have these issues affected your:
¿Cómo han afectado estos problemas a su:
🔬 Clinical Observations / Observaciones Clínicas
(For clinician use) Based on the FIDO assessment, document key observations about presentation, affect, and behavioral patterns.
(Para uso del clínico) Basado en la evaluación FIDO, documente observaciones clave sobre la presentación, el afecto y los patrones de comportamiento.
📋 Assessment Summary / Resumen de la Evaluación
🧬 Clinical Impressions & Diagnosis / Impresiones Clínicas y Diagnóstico
✍️ Clinician Signature / Firma del Clínico
📊 PHQ-9 - Patient Health Questionnaire (Depression)
Over the last 2 weeks, how often have you been bothered by any of the following problems?
0 = Not at all | 1 = Several days | 2 = More than half the days | 3 = Nearly every day
📊 GAD-7 - Generalized Anxiety Disorder Scale
Over the last 2 weeks, how often have you been bothered by the following problems?
0 = Not at all | 1 = Several days | 2 = More than half the days | 3 = Nearly every day
📈 Screening History
No previous screenings recorded for this patient.
🎙️ Record / Transcribe for Bio-Psychosocial
Ready🔒 Audio is processed securely via Whisper API and never stored permanently.
⚠️ Presenting Problem(s)
📚 Developmental / Social History
👨👩👧👦 Family / Social Network
🧠 Mental Status Examination (MSE)
💊 Medical / Psychiatric History
⚠️ Abuse History
Client reports that:
| Type | As Child | As Adult |
|---|---|---|
| Was sexually abused? | ||
| Sexually abused others? | ||
| Was physically abused? | ||
| Physically abused others? | ||
| Was emotionally abused? | ||
| Emotionally abused others? |
🍷 Substance Use / Alcohol Drug Screen
| Substance | Days Used | Avg Amount |
|---|---|---|
| a) Alcohol (ETOH) | ||
| b) Marijuana | ||
| c) Cocaine/Crack/Meth | ||
| d) Heroin/Opiates | ||
| e) Pain pills (not prescribed) | ||
| f) Tranquilizers/Sleeping pills | ||
| g) LSD/Hallucinogens | ||
| h) Other |
💼 Employment History
⚖️ Legal History
🤝 Social Services Involvement / Needs
🩹 Pain Screening & Assessment
🚨 Suicide Risk Assessment
📝 Summary & Recommendations
🧬 Diagnosis
✍️ Signatures
Within 10 working days from the above date a licensed practitioner of the healing arts (LPHA) must review and sign.
🎙️ Record / Transcribe for FARS/CFARS
Ready🔒 Audio is processed securely via Whisper API and never stored permanently.
🏥 Diagnosis Information
📋 Service Information
📊 Evaluation Details
📊 Problem Severity Rating Scales
1=No Problem → 9=Extreme Problem✍️ Signatures & Certification
🎙️ Record / Transcribe for Treatment Plan
Ready🔒 Audio is processed securely via Whisper API and never stored permanently.
📋 Service Information
🏥 Diagnosis Information
⚠️ Presenting Problems & Strengths
📋 FL Medicaid Required Clinical Information
Required for authorization🎯 Problems Identification
🏥 Additional Diagnoses (B-L)
Click to expand💊 Service Modalities & Frequency
| Service | Code | ✓ | Units | Frequency | Duration |
|---|---|---|---|---|---|
| Individual Outpatient Therapy | H2019|HR | Weekly | |||
| TBOS (Therapeutic Behavioral On-Site) | H2019|HO | Monthly | |||
| Family Therapy | 90847 | Monthly | |||
| Group Therapy | H2019|HQ | Weekly | |||
| Treatment Plan (Initial) | H0032 | 1 time | Per Year | ||
| Treatment Plan Review | H0032|TS | 4 times | Per Year | ||
| Limited Functional Assessment (CFARS) | H0031 | 3 times | Per Year | ||
| Bio-Psychosocial Evaluation | H0031|HN | 1 time | Per Year | ||
| In-Depth Assessment | H0031|HO/TS | 1 time | Per Year | ||
| Psychiatric Evaluation | H2000|HP | As needed | |||
| Medication Management | T1015 | Monthly | |||
| Psychosocial Rehabilitation (PSR) | H2017 | Weekly | |||
| Crisis Intervention | 90839 | As needed | 6 months | ||
| Targeted Case Management (TCM) | T1017 | Monthly |
🏥 PSR & TCM Service Assessment
Assess medical necessity for Psychosocial Rehabilitation (PSR) and Targeted Case Management (TCM) services.
✍️ Signatures & Certification
🎙️ Record / Transcribe for TX Plan Review
Ready🔒 Audio is processed securely via Whisper API and never stored permanently.
Import problems, objectives, and diagnoses from the Master Treatment Plan
📋 Review Information
🎯 Discharge Plan
🔗 Coordination of Care
A. Patient Clinical Information
B. PCP/Medical Practitioner Information
🔄 Changes in Individualized Treatment Plan
This review is based on the following events between the review period:
📋 Client Status & Treatment History
📊 EXISTING Treatment Plan Problems and Goals
⚠️ No problems loaded yet.
Click "Load Treatment Plan Data" to import existing problems and objectives.
➕ ADD NEW Treatment Plan Problem(s) and Goal(s)
💊 Interventions / Services
| Type of Service | Billing Code | Amount | Frequency | Duration | ✓ |
|---|---|---|---|---|---|
| Individual Outpatient Therapy | 90837 | Weekly | 6 Months | ||
| TBOS (Therapeutic Behavioral On-Site) | H2019|HO | Monthly | 6 Months | ||
| Treatment Plan Review | H0032|TS | 4x/Year | Per Year | ||
| Family Therapy | 90847 | Monthly | 6 Months | ||
| Group Therapy | 90853 | Weekly | 6 Months | ||
| Limited Functional Assessment (CFARS) | H0031 | 3x/Year | Per Year |
📜 Certification Statement
📈 Overall Progress Summary
✍️ Signatures
🎙️ Record / Transcribe for Progress Note
Ready🔒 Audio is processed securely via Whisper API and never stored permanently.
Load problems, objectives, and diagnoses from the patient's Treatment Plan
⚠️ Problems Addressed from Treatment Plan
📋 No problems loaded yet.
Select a patient and click "Load Treatment Plan" to import their problems.
🏥 Diagnosis Information
📋 Service Information
👤 Client Presentation
🧠 Mental Status Examination (MSE)
| Domain | Finding |
|---|---|
| Mood | |
| Affect | |
| Speech | |
| Thought Process | |
| Thought Content | |
| Perception | |
| Orientation | |
| Memory | |
| Insight | |
| Judgment |
💊 Current Medications
| Medication | Dosage | Frequency | Prescriber | Compliance | |
|---|---|---|---|---|---|
📊 Screening Scores (This Session)
📝 Visit Note — Session Narrative
Describe what occurred during the session: topics discussed, interventions delivered, client's participation and response, clinical observations, and progress toward treatment goals.
📝 SOAP Note
💊 Interventions Used This Session
📋 Treatment Plan (Objectives Progress)
📋 This section will auto-populate when Treatment Plan is loaded above.
⚠️ Risk Assessment
📆 Next Session & Continuity of Care
📎 Addendum & Copayment
✅ Patient Consent
✍️ Signatures
I, the Licensed Mental Health Counselor or Licensed Clinical Social Worker, Medicaid Provider, have read and approved the proposed interventions and agree that the services herein are medically necessary based on Florida Medicaid Community Mental Health standards and definitions.
This information has been disclosed to you from records whose confidentiality is protected by state law. State law prohibits you from making any further disclosure of such information without the specific written consent of the person to whom such information pertains, or as otherwise permitted by state law. A general authorization for the release of medical or other information is NOT sufficient for this purpose.
Confidential & Privileged Information for Professional Use Only
🎙️ Record / Transcribe for Discharge Summary
Ready🔒 Audio is processed securely via Whisper API and never stored permanently.
🧬 Primary Diagnosis (A)
🔚 Discharge Information
Discharge Planning Process:
| Criteria | Yes | No | N/A | Explanation (if not met) |
|---|---|---|---|---|
| Discharge planning started from first day and regularly assessed | ||||
| Conducted in collaboration with team, member, family, supports | ||||
| Plan documented and approved by member | ||||
| Services adjusted based on needs to determine discharge time | ||||
| Discharge occurred when goals met / baseline / max benefit achieved |
Step-Down Planning Process:
| Criteria | Yes | No | N/A | Explanation (if not met) |
|---|---|---|---|---|
| Step-down planning began when member improved and reached goals | ||||
| Treatment recommendations followed, no severe dysfunction | ||||
| Skills reinforced (self-care, coping, support systems) | ||||
| Community resources explored before discharge | ||||
| Discharge plans/guidelines provided to resume services if needed |
Coordination of Care:
| Criteria | Yes | No | N/A | Explanation (if not met) |
|---|---|---|---|---|
| Intentional information exchange between care participants | ||||
| Coordination involved team, external providers, and family | ||||
| Previous provider records reviewed to align care | ||||
| Member/guardian notified about care coordination | ||||
| Conflicting treatment plans or service duplication avoided |
Service Transition Evaluation:
| Criteria | Yes | No | N/A | Explanation (if not met) |
|---|---|---|---|---|
| Service reduction based on member's progress | ||||
| Independence and effective functioning of member ensured | ||||
| Treatment individualized according to problem severity | ||||
| Unhealthy attachment to treatment providers prevented | ||||
| Services adjusted with medical justification and authorization |
Client:
Parent/Legal Guardian:
Provider:
Supervisor (LPHA):
🎙️ Record / Transcribe for In-Depth Assessment
Ready🏥 Additional Diagnoses (B-L)
Click to expand👨👩👧 Caretaker/Child Interactions
📜 History of Past Treatment
⚠️ Presenting Symptoms & Behaviors
👶 Developmental History
🏥 Medical History
🍷 Alcohol/Drug Screen
👨👩👧👦 Family Psychosocial History
⚖️ Client Legal Issues
🧠 Mental Health Status Examination
🚨 Suicide Risk Assessment
📝 Integrated Summary
🧬 Diagnosis
💡 Recommendations
✍️ Signatures
👤 Patient Data
🚫 MHC Missed Visit Details
| Missed Visit Date | Authorization | Discipline Missed | Reason for Missed Visit | Parent/Guardian Notified | Disciplines Notified of Discharge | |
|---|---|---|---|---|---|---|
💬 Comments
✍️ Behavioral Signature
This information has been disclosed to you from records whose confidentiality is protected by state law. State law prohibits you from making any further disclosure of such information without the specific written consent of the person to whom such information pertains, or as otherwise permitted by state law. A general authorization for the release of medical or other information is NOT sufficient for this purpose.
Confidential & Privileged Information for Professional Use Only
🔑 AI Configuration
The AI assistant uses the server-side proxy (api-proxy.php) for secure API calls.
🤖 AI Auto-Fill — All Documents at Once
📝 Master Session Transcription
Auto-Fill Target Documents
📁 My Documents
| Patient | MRI | Type | Status | Date | Actions |
|---|---|---|---|---|---|
| Select provider to view documents | |||||
🔗 Assign Patients to Providers
📋 Unassigned Patients 0
👨⚕️ Assign to Provider
👨⚕️ Manage Providers
Carrousel@25!
| Name | Role | Credentials | NPI | Patients | Actions |
|---|
🔐 Security Settings
Admin Password
Change the administrator password
Reset All Providers
Reset all provider passwords to default
Session Info
Logged in as: Administrator
👥 All Patients
| MRI | Name | DOB | Type | Phone | Provider | Status | Actions |
|---|
📈 Statistics
🔍 Audit Management Dashboard
📊 Recent Audit Activity
| Date | Insurance | Patient | Document | QA Score | Status |
|---|---|---|---|---|---|
| No audit cases yet. Click "+ New Audit Case" to start. | |||||
🏥 Audit Cases by Insurance
📁 Audit Cases
| Case ID | Patient | Insurance | Request Date | Due Date | Documents | QA | Status | Actions |
|---|---|---|---|---|---|---|---|---|
| No audit cases. Click "+ New Case" to create one. | ||||||||
📤 Upload Audit Documents
Drag & Drop files here
or click to browse — PDF, DOC, DOCX, JPG, PNG accepted
📄 Documents in Selected Case
| Filename | Type | Uploaded | QA Status | Actions | |
|---|---|---|---|---|---|
| Select an audit case above to see documents | |||||
✅ Audit QA Review
Select an audit case and click "Run QA Check" to validate documents.
📋 QA Validation Standards
Valid license number, NPI, credentials after name, signature present
Full name, DOB, MRI/ID, insurance ID, consent on file
ICD-10 codes, CPT codes, medical necessity documented
Date/time, duration matches billing, session type, location
Goals addressed, objectives measured, interventions match plan
Joint Commission standards, Medicaid/Medicare requirements met
📜 Audit Activity Log
| Timestamp | Case | Action | User | Details |
|---|---|---|---|---|
| No audit activity logged yet. | ||||