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Assessments and Care Plans: Simultaneous Documentation

This guide walks you through how to manage assessments and update the Care Plan at the same time. Keeping both open in separate windows allows for accurate, up-to-date documentation — without switching back and forth.

Overview

Use this workflow when:

  • Completing an assessment that may lead to updates in the Care Plan

  • Adding actions, resources, or memos based on a client’s identified needs

  • Ensuring each Care Plan update is tied to the correct Activity Date

Steps to Document Assessments and Update the Care Plan

  • Open the Client Profile

    • Locate and open the client from the Client List.

    • Navigate to the appropriate assessment and open it.

  • Unlock and Review the Assessment

    • Use the lock toggle to unlock the assessment for editing.

    • Review the questions and responses to identify areas tied to client needs.

  • Open the Care Plan

    • Click the Care Plan button to launch it in a separate window.

    • Use the Expand All feature to display all details at once.

  • Confirm the Activity Date

    • Check the Activity Date in the assessment. This date links any Care Plan updates you make during this session.

  • Review Key Sections in the Care Plan

    • Assessment Memos

    • Identified Needs

    • Linked Resources

Updating the Care Plan

  • Update an Existing Problem/Need

    • Find the relevant item in the Care Plan.

    • Click the Edit icon to view or update actions and notes.

  • Add a New Action or Follow-Up

    • Select the related resource or need.

    • Click the New Action icon.

    • Choose the appropriate action and confirm that it links to the current assessment.

    • Click Add to save.

  • Add Notes for Non-TCM Needs

    • Use the New Memo icon to add a free-text note.

    • The memo automatically links to the assessment and reflects its Activity Date.

Cautionary Notes

  • Select the Correct Assessment and Date

    • Always confirm that new actions or memos are linked to the correct activity.

  • Avoid Data Loss

    • Double-check before editing or deleting existing items in the Care Plan.

  • Accuracy Matters

    • Mistakes in dates or mismatched links can impact client care and reporting.

Tips for Working Efficiently

  • Use Two Windows

    • Keep the Assessment and Care Plan open side by side for easier cross-referencing.

  • Use Expand All

    • Quickly view the full Care Plan by clicking Expand All.

  • Check the Edit Icon History

    • Use the Edit feature to review when actions or resources were last updated — and by whom.

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.