Client File - SAP

Client File - SAP

The client file is designed to track all information and time related to a case. Each client file has tabs attached located across the middle of the form. Client files can be made up of one, two or more individuals depending on the nature of the case. Adding one client file impacts the utilization for a company by one (1). You must define a "case" or "file" and apply that definition to EAP Expert 3 —we do not do this as definitions vary from SAP to SAP.

Fields on the main form include:  Name List, Date Opened, Date Closed, Include In Utilization/No Show, Presenting Problems, Case Status and Contacts.

Adding a New SAP Client File (Client does not exist in system)

1. Ensure that the client does not exist already in the system by clicking on Client Files in the left module bar and searching for their name and organization etc. If they do exist, follow the steps of adding an SAP File to an existing client, otherwise proceed to step 2.

2. Click the New button in the top tool bar

3. Select Client File then SAP Client File

4. You will then be presented with an SAP file consisting of two parts: Details (personal information about the client) and SAP - 0 (information relating to the case...the file number begins at 0 but will be assigned a new number after it has been saved)

5. Complete the Details Tab including name, address, contact information and personal information.

6. Complete the SAP - 0 Tab case information including organization, presenting problems, authorization(s), activity, assessments etc.  Ensure that all reportable data is captured or you risk your report totals being off. 

Tip: Right-mouse click over a field and select ‘Required’ for those fields that must be entered. Most fields have 3 Required options:

• Required – Can be set at any time and will not allow the user to Save without entering a value
• Required At Open – Will not allow the user to Save without entering a value after creating a new fie
• Required At Close – Will not allow the user to Save without entering a value after entering a Date Closed

Note: The organization field stays with the File, allowing the client to switch companies but not lose their history (see Details below)

7. Click the Save button to save the client and file or click the Save & Close button to both save the client/file and close them both.

Adding a New SAP Client File (Client exists in system)

1. Click the Client Files module item in the left module bar

2. The Client File search will display

3. Enter in your search information e.g. First Name, Last Name, Organization etc.

4. Click the Search button on the top tool bar or in the Search Criteria frame

5. In the Search Results grid, locate the Client/File you would like to add the case to (you can open up an previous file for the client)

6. Double-click the Client/File to open it up

7. Click the Add File button (beside the New button) in the top tool bar and choose SAP File

8. Complete the SAP - 0 Tab case information including organization, presenting problems, authorization(s), activity, assessments etc.  Ensure that all reportable data is captured or you risk your report totals being off.

Note: The organization field stays with the File, allowing the client to switch companies but not lose their history (see Details below)

9. Click the Save button to save the client and file or click the Save & Close button to both save the client/file and close them both.

Editing an Existing SAP Client File (Client exists in system)

1. Click the Client Files module item in the left module bar

2. The Client File search will display

3. Enter in your search information e.g. First Name, Last Name, Organization etc.

4. Click the Search button on the top tool bar or in the Search Criteria frame

5. In the Search Results grid, locate the Client/File you would like to add the case to (you can open up an previous file for the client)

6. Double-click the Client/File to open it up

7. Edit the SAP File or Client Details tab

8. Click the Save button to save the client and file or click the Save & Close button to both save the client/file and close them both.

Deleting an Existing SAP Client File (Client exists in system)

1. Click the Client Files module item in the left module bar

2. The Client File search will display

3. Enter in your search information e.g. First Name, Last Name, Organization etc.

4. Click the Search button on the top tool bar or in the Search Criteria frame

5. In the Search Results grid, locate the Client/File you would like to delete 

6. Double-click the Client/File to open it up

7. Click the red "X" in the top tool bar to delete the file

8. Answer "Yes" when prompted to delete the record

Client File Tabs:

• Names List
• Sessions/Activities
• Authorizations
• Details
• Closing Details
• Documents/Attachments
• Demographic Set
• Related
• Additional Info
• Intake Notes
• Clinical Notes
• Feedback
• Referral

Names List

This grid will automatically populate with the client information entered in the Details and SAP – 0 tabs. Field included are:

• Client Name – auto populates from Details tab
• Organization – auto populates from Details tab
• Client Type – Must be entered by user in this form
• Primary – Indicates primary person linked to the file. Defaults as checked
• Service Request – Indicates that they requested the service. Defaults as checked
• Service User – Indicates that they are using the service. Defaults as checked

To add one, two or more people to the file, click on the Add button in the form and select New Person. A Client Search form will appear to allow to check if this person has already accessed the service in the past.  If you find the individual, click on the name and then click on the OK button.  You will then select the Client Type and change the Organization (if necessary). The Service User check box will default to checked. If you cannot find the individual, click on the Create New button and Client form will appear.  Enter their Name and any other information you may be required to collect.

Sessions/Activities

This grid will allow the user to enter Sessions or Activities for that file. There are 4 options to choose from:

• Activity – Any activity that is non session related i.e. Case Management or Follow up
• Case Consultation – Activity where two clinicians or a clinician and their supervisor discuss the case
• Provider Session – A session completed by an Affiliate/Provider
• Session – A session completed by a Counselor on staff.

Creating a Session / Provider Session

1. Click on the New button in the form and select one the two options
2. For both Session and Provider Session, key information to enter include: Date, Duration, Session Type, Staff/Counselor. Check boxes include: High Risk File, Show on Utilization Report, Billable, Urgent Appointment, Count As Session, Cancellation, No Show.
3. Next, there are 4 Tabs located across the form for entering Notes or Details. They include:

• Clinical Notes – Click New to add a Note. Notes from the session can be entered here.  They can also be set to lock after a certain period of time in order to prevent any future changes.
• Session Notes - Click New to add a Note. Notes from the session can be entered here. These notes cannot be locked.
• Phone Details – Lists the client’s phone information
• Intake Notes – Notes from Intake staff can be entered here.

***Please note that Spell Check is only available in the Clinical Notes tab***

Creating an Activity or Case Consultation

1. Click on the New button in the form and select one the two options
2. Key information to enter include: Date, Duration, Activity Type, Staff/Counselor and Case Manager (Case Consultation Only). Check boxes include: Show on Utilization Report and Billable.

Authorizations

Creating An Authorization

1. Open an existing file or create a new file for the client. Click on the Authorization tab within the Client File
2. Next, click New in the Authorization toolbar and the Authorization form will pop-up
3. Select or Search (click on binoculars) for the provider you wish to Authorize sessions to
4. The number of sessions, the duration and hourly rate should default if they have been setup in Organization Current Contract (number of sessions) and Clinical Resources (provider hourly rate). Enter your start date and end date for this authorization (an end date is important as it allows you to control your payables and ensures providers do not stretch appointments and gets their billing in in a timely manner
5. Click the Save icon in the Authorization toolbar to Save this Authorization. An authorization number will be assigned (click the Refresh button to change it from "0" to the real Authorization Number
6. When the provider sends in their invoice and paperwork, you can enter in the details of the sessions using the Authorization Number. You can enter them quickly into the system using the Provider Claims module.

Note: If the provider requires additional sessions, repeat steps 1 through 6 but change the default number of sessions to whatever you have agreed upon. There is no limit on how many Authorizations you can create per Client File.

Details

The Details Tab is designed to capture additional file information. The fields include: Risk Code, Impact of Problem, Paper File # (used if you have your own internal file numbering system), First Appointment Offered, First Appointment Decline Reason and First Appointment Offered Note section.

Closing Details

The Closing Details Tab is designed to capture additional information when closing a file. The fields include: Resolution, Outcome, GAF, Achievement of Counseling Goals, Performance Impairment, Absence, Recommendation, Assessed Problems, DSMIV codes, Client Satisfaction Survey Distributed check box, and a Notes Section.

Documents/Attachments (Client File)

The Attachments tab allows users to attach documents to a Client File. It may be signed forms, notes, or any other documents related to the file.

To "Attach" a document, simply click the Documents/Attachments tab;

1. Click NEW and then Documents/Attachments
2. Enter the Document Name and Type
3. There are two methods to attach documents:
   1. a.    Attachment (Stored in DB): This will save the file within the EAP Expert database. Click on the Attachment field “…” to search for the file you want to attach, then click the OPEN button to add the document. Save and Close.
   2. b.    Direct Path: This will create a link to the file stored on your local drive or server. Click on the Attachment field “…” to search for the file you want to attach, then click the OPEN button to add the document. Save and Close.

To "Delete" a document, simply right-mouse-click over the item in the window, then choose Delete.

To "view or open" the document, simply double click on the row. Drag your mouse over the attachment field (and in particular, the file name) until the mouse pointer turns into a hand. Now click the file name to open the document.

To "launch" the document, simply left mouse-click the item in the window, then click the item to launch it!

Demographic Set (Client File)

This tab tracks information relating to the employee. A spouse or dependent may also be able to provide this information.  It is important to decide when to use this form and make it a business rule. There are many SAPs who will ask spouses and family members information pertaining to the employee e.g. occupation, division, and length of employment.

It is strongly suggested you leave this form blank (unless your utilization report requires a divisional breakdown report) unless you get this information from the employee who attended the session. The reason being is that there is a high risk that information gathered from family members is incorrect and your clients may possibly make inferences on data that may not be related to their company e.g. Three spouses accessing the SAP for addiction issues may provide "sales" as the department the employee works in—the danger now is that your client makes the inference that the sales’ department has addictions issues.

These demographics are specific to the Organization/Group you are currently viewing (they may differ to other demographics collected for other companies). These can be customized in Demographics (Organization/Groups)

Related

The Related Tab is designed to link other Files or Organizational Services to file that is open.

To "Add” a Client File, simply click the Files tab;

1. Click Add and then type in the File # or Client’s Name in the Find field and click GO!
2. Select the file in the results below and then click Ok
3. To remove a link to a file, simply select it from the grid below and then click on the Remove button.

To "Add” an Organizational Service, simply click the Organizational Services tab;

1. Click in the drop down field and then type in the Organizational Service # and click GO!
2. Select the file in the results below and then click Ok
3. To remove a link to a file, simply select it from the grid below and then click on the Remove button.

Additional Info

The Additional Info Tab is designed to capture information that does not appear on the client file form. For example, let’s say there are one or two fields you don't see on the current form that you would like to add (e.g. Date of Employment, Business Unit). You would first need to go to the Survey Module, Choose Client File Additional Info, then create a new survey with these two new fields added.

It can also be used to add surveys or forms such as an Initial Assessment or Drug Screen.

See Surveys on how to create a new survey/form.

To add an Additional Info Survey or Form to a client file, simply click on the New button within the form and select Additional Info.  Click on the one needed in the Question Set window that appears and click Ok.  It now becomes part of the client file.

Intake Notes

Notes taken at the time of the client’s first call by Intake staff can be entered here.

Clinical Notes

Counselors can enter their notes from each session in this Tab.  Click New to add a Note. Various formatting options are available and notes can be set to lock after a certain period of time in order to prevent any future changes. This Tab can be used by counselors who would prefer to enter their notes in one location rather than in each Session.

Feedback

The Feedback tab allows the user to enter any positive comments or complaints received from the client that may be initiated by a phone call, email, in person or by letter.  This section is not meant for satisfaction surveys. These would be entered in the Satisfaction Survey module.

 To ADD feedback, simply click the Feedback tab;

1. Click Add and then search for an existing feedback response. Click on the feedback and then click OK to link it to the file.
2. If entering new feedback, click on the New button
3. Search for the File and once found, click on the row to select
4. Select the Feedback Type, Activity Type, Date and Time resolved
5. Details of the feedback can be entered by clicking on the Details tab
6. Action items can be entered by clicking on the Plan of Action tab
7. Any outcome information can be entered by clicking on the Outcome tab
8. Any staff involved can be added by clicking on the Staff Involved tab
   1. Click on Add to find the staff member, select their name and then click on Ok to confirm
   2. Click on Remove to remove any staff from the list.
   3. To add an activity to document time spent, click on the Feedback Activity tab
      1. Click on the New button and select Feedback Activity
      2. Enter the Date, Time, Duration, Modality, Feedback Activity Type, and Notes below. Click on the check box for Show on Utilization Report if you would like the time spent to appear in Account Management Hours.

10. The Additional Info Tab is designed to capture information that does not appear on the feedback form.

11. Creating a New Feedback Question Set

1. In the top tool bar, click on New button, then Question Set
2. Choose the Additional Info Category
3. Provide a Name for the Question Set
4. Click on the New button and select the question format
5. Enter the question text and then click New in the Answers section to enter the answer options (does not apply to Date, Decimal, Memo, Number and Text
6. Repeat the above steps for each additional question
7. Click on Clear Layout to Refresh the screen to see the questions appear
8. To move the order of the questions, right-mouse click, select Customize Layout and then click, drag and drop the question in the appropriate order.

Referral

This grid will allow the user to enter a referral(s) to clinical resources outside of the SAP Program.  Such resources may include self-help groups, AA, or other community resources. for that file.

Creating a Referral

1. Click on the New button in the form and select Referral
2. Click on the Referred To drop down to select from a list of community resources or on the magnifying glass to Search using the Clinical Resource Search window
3. Select the date referred from the Referred Date.  Today’s date will be the default
4. Select a problem for Referral Problem drop down.  If one does not exist in the list, simply click on the New button to add one. Security settings may prevent this. If so, check with your administrator or staff member who can create one for you
5. Add any notes regarding the referral in the Notes section
6. Check the Accepted check box if the clients accepts the referral.