Details TAB
OT Ax TAB
The Auth Tab
The OT MHSU Assessment is a standardized template allowing clinician’s variability to document a comprehensive client assessment from the perspective of Occupational Therapy Mental Health and Substance Use. It is used regionally by all OT clinicians at community MHSU teams.
The OT MHSU Assessment has 3 tabs
The 3 tabs are located at the bottom of the form as shown below and are Details, OT Ax, and Authorization.
Details TAB
Upon creating the OT MHSU Assessment, the Details sub-tab will be visible. This form captures the mandatory “Date Started” date field along with optional assessment details. Once this assessment is completed, the user can print this assessment under the “Form Tools’ section using the Print Form button.
OT Ax TAB
The Assessment Tab provides an unlimited free text assessment section. This section contains preloaded headings designed to support practice.
Any questions regarding how to use, or revise, the template within the assessment, should be directed to your Practice Coordinator or Clinical Resource Therapist.
The free text assessment section is supported with basic text formatting functionality. Formatting options can be accessed on the 2 toolbars at the top of the section and common word processing keyboard shortcuts work in the free text section, such as Ctrl+C to copy or Ctrl+B to bold text. Click your cursor below a header to begin typing.
Tip: Allergies are always entered into the client banner as per VCH policy
The Auth Tab
The Auth tab is used to authorize and close the Assessment.
- Assessments must be read and authorized by the author.
- The Carried Out By and End Date fields displaying in the Header Details are entered in the Authorization tab.
- Narrative Assessments for MH are end dated or closed from the Authorization tab.
Check your program guidelines to see which Assessments require “authorization” as a final step.
Assessments become Read Only once the Closing Authorizer and date have been entered and cannot be edited.
Related Links
Allergy Documentation Policy
MH Authorizing Dictated Assessments
End Date an Assessment
Mark Assessment Entered in Error