Details of mental health assessments can be entered on the “Assessment” subtab of the “MH” tab.

When you select the MH tab, you will be at the “Basic” subtab by default. Click on the “Assessment” sub-tab to begin entering mental health screening and assessment records to a client’s mental health file.

Figure 1. “Assessment” subtab

Your access to this sub-tab can be limited to read only, full edit access or none at all. If you do not have access to this sub-tab in the MH tab, you will not see this tab at all. If you do not have access to any of the MH sub-tabs, you will not see the MH tab in a case. This depends on the role assigned to you in Trak.

To learn how to manage privileges for the Mental Health Tab and its sub-tabs, see the help file for “Roles.”

STEP 1: Select “Add New Assessment”

On the Assessment sub-tab, click on the “Add New Assessment” button to begin to enter details about your mental health assessment for the client.

Figure 2. “Add New Assessment” button

STEP 2: Enter Assessment Details

An Edit dialog box will come up with different fields for you to fill out regarding your

assessment.

Click on the “Assessment Instrument” dropdown list to select which one was used with the client.

Figure 3. “Assessment Instrument” list

NOTE: A list of common, evidenced-based Assessment Instruments has been pre-populated in this field. See “Add New Assessment Instruments,” below, for instructions on how to add additional Assessment Instruments to this list.

Enter the date of the session in the “Session Date” field and the date the Assessment was done in the “Assessment Date” field. These fields show today’s date by default if none has been set yet.

Figure 4. “Session Date,” and “Assessment Date” fields

Select the appropriate “Provider Agency” and “Provider Personnel” who conducted the assessment from the drop down menus.

Figure 5. “Provider Agency,” and “Provider Personnel” fields

STEP 3: Enter Assessment Measure Scores

Once an Assessment Instrument is selected from the “Assessment Instrument” dropdown list, the Assessment’s scoring measures will auto populate in the “Scores of this Assessment’s Measures” section.

Enter the scores from the client’s assessment in the available fields to record your scores for this assessment. You can add any notes related to the assessment to the “Comments” text box.

Figure 6. “Scores of this Assessment’s Measures” fields

STEP 4: Save Assessment Details

Once you have completed entering all details for the assessment, click on the “Update” button to save the record and return to the list of Assessments, or “Cancel” to forego adding a new Assessment.

Figure 7. “Update,” and “Cancel” buttons

Repeat the process to add other assessments if necessary. These assessments may be administered with different Assessment Instruments or records of the same Assessment Instrument may be entered to show a client’s progress during treatment.

Every time a new assessment has been added, it will appear at the top of the list in the table for Assessments Given.

You can sort the different columns in the table, i.e. sort the names of the Assessment Instruments alphabetically or sort the dates from latest to oldest or vice versa. To do this, you just have to click on the column name once and it will sort. If you click on the same column name, it will sort in the reverse order.

For example, you want to sort by date. When you click on the Date column once, it will sort the entries from oldest to latest and an upward arrow will appear beside the column name. If you click on the Date column again, it will sort the entries in reverse order and a downward arrow will appear beside the column name.

Figure 8. Sorting assessments by “Date”

Figure 9. Sorting assessments by “Date” in reverse order

To make changes in one of the entries in the “Assessments Given” table, choose the entry you want to modify and click on the “Edit” button next to it to review and change the details.

Figure 10. “Edit” button

Once you click on Edit, the details of the selected assessment will come up in the Edit dialog box.

Make changes to any field and click on the “Update” button, or select “Cancel” to forego any edits.

The dialog box will close and you will be back at the “Assessments Given” table.

For detailed instructions on making selections in each field of the Assessment menu, see “Add a New Assessment” above.

To delete an assessment, click on the Delete button beside the assessment you want to delete. A dialog box will come up asking you to confirm the deletion.

Figure 11. Delete confirmation dialog box

If you click OK, the dialog box will close and the selected entry in the “Assessments Given” table will be deleted. If you click Cancel, the dialog box closes and the selected assessment will not be removed.

STEP 1: Select “Add New” Assessment Instrument in the Assessment Sub-tab.

Common Assessment Instruments have been included in the list of Assessment Instruments options.

Additional Assessment Instruments can be added to this list to be made available for your CAC whenever entering a new Assessment record.

On the Assessment subtab, click on the “Add New Assessment” button. An Edit dialog box will appear with a menu of options to include in the details about the Assessment.

Click on the “Add” link next to the Assessment Instruments field.

Figure 12. “Add” an Assessment Instrument

The “Edit Assessment Instrument” box will appear. It will include the current list of Assessment Instruments.

STEP 2: Select “Add New Instrument”

Click on the “Add New Instrument” button at the top of the Edit Assessment Instrument box. Open fields will appear to allow you to enter a new Assessment Instrument and its associated assessment measures.

Figure 13. “Add New Instrument” button

Type in the name of the new Assessment Instrument that you want to add in the field under the Assessment Instrument column.

Figure 14. Assessment Instrument name text box

Click on the arrowhead pointing to the right just beside the “Update” and “Cancel” buttons. This will expand the menu so you can enter the measures associated with the new Assessment Instrument that you want to add.

Figure 15. Arrow button to expand menu

Click on “Add New Measure” button to enter the measures for the new Assessment Instrument. In the “Measure” field, type the name of the Measure and provide a description of the Measure in the “Description” field.

Select “Update” to save the measure.

Figure 16. “Measure,” and “Description text boxes

Repeat this process to add more Assessment Measures to the Assessment Instrument. Once all of the Measures are entered select the “Update” button next to the Assessment Instrument at the top.

NOTE: Every Assessment needs to have at least one measure. If you do not enter a Measure, the system will not allow you to save the Assessment Instrument to the list.

STEP 3: Review and Edit Assessment Instruments and Measures

To review and make changes to any Assessment Instrument and associated Measures, click on the “Edit” button to the left of the Assessment Instrument in the list.

Figure 17. “Edit” button

Once changes are made, click on the “Update” button to save your changes and return to the list of Assessment Instruments, or click “Cancel” to forego any edits.

STEP 1: Select “Add New” Diagnosis in the Assessment Subtab.

On the Assessment subtab, click on the “Add Diagnosis” button to enter a new one in the “Diagnosis Log” section of the Assessment sub-tab.

Figure 18. “Add Diagnosis” button

A dialog box will appear with a menu of options to include in the details about the Diagnosis.

STEP 2: Enter Diagnosis Details

Select the appropriate “Provider Agency” and “Provider Personnel.”

Enter the “Diagnosis Date,” and select the appropriate “ICD 10 Group” and “ICD 10 Diagnosis” codes.

Select “Update” to save the record and return to the list or “Cancel” to forego adding a New Diagnosis.

Figure 19. “Provider Agency,” “Provider Personnel,” “Diagnosis Date,” ICD 10 Group,” and “ICD 10 Diagnosis” fields

Repeat this process to add more Diagnoses to the Diagnosis Log as necessary.

STEP 3: Review and Edit Diagnoses

To review and make changes to any Diagnosis record, click on the “Edit” button to the left of the Diagnosis in the list.

Once changes are made, click on the “Update” button to return save your edits and return to the list.

To delete a Diagnosis record, click on the “Delete” button. A pop up box will ask, “Are you sure you want to delete this record?”. Click on “OK” to delete or “Cancel” to forego deleting the record.

Figure 20. “Edit,” and “Delete” buttons

Document Upload

To upload documents related to assessments given to clients and their diagnoses, scroll down to the “Document Upload” section. This is available in every MH subtab. Files uploaded in one subtab are NOT visible in other sub-tabs.

Use the “Select Files” button to upload files.

Figure 21. “Select Files” button in the document upload section

Refer to the “Document Upload” help file for details on uploading and managing documents.

NOTE: NCA does not recommend the storage of evidentiary documents as part of this case record. Any copies of evidentiary materials should be retained by the appropriate law enforcement and prosecution partners.