Instructions For CompuPIE _1_
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CompuPIE Instructions This section instructs readers how to navigate and use the CompuPIE software. CompuPIE is the software tool for the PIE (Person in Environment) System. For users not familiar with the PIE system, please refer to New Users of the PIE System before reading these Instructions. After downloading CompuPIE and entering user name and password, the user is taken to the Home or The Welcome Page. This page contains 6 Buttons: Open New Case Open Existing Case New to PIE CompuPie Instructions Dedication About the Author As noted, the New to PIE button provides a detailed overview of the PIE system. The Dedication and About the Author buttons provide information on their respective topics. Relevant to conducting a comprehensive biopsychosocial assessment or PIE assessment of your client are the Open New Case and Open Existing Case buttons. Open Existing Case allows the user to open a new case to conduct a comprehensive PIE assessment, modify an assessment, add progress notes and conduct follow up assessments. Open New Case. When you click on “Open New Case” the screen for inputting client information such as name, address, ID number, contact information, etc. is displayed. There are pull down menus for a number of categories, for example, gender, occupation, level of education, employment status and living arrangement. There is also a box to type in any other relevant socio demographic information. The menu on the left side of the screen includes the components of a PIE assessment. Each is discussed below. Case History (Including trauma history and substance use) Factor 1 Factor 2 Factor 3 MSE or Mental Status Exam Factor 4 Strengths & Resources Additional notes 1 Report (for printing the report or pdf to save). Case History. This screen includes the following: Reason for Referral, Current Situation and Relevant History. There are also checkboxes to indicate childhood trauma as well as traumas experienced in adulthood. Check as many boxes as applicable to your client. There is also a section, Notes for Trauma History, where the user can discuss relevant trauma in more detail. The next screen is a checklist for Substance Abuse. The user indicates the number of times in the past 30 days as well as lifetime use (in years) that the client has used various substances. If a substance is not included in the list, the user can write in the relevant drug. This list should not include drugs/medications that were prescribed by a physician. Remember, further information regarding substance abuse should also be indicated in Factor 3 using the relevant DSM 5 diagnosis. When done click the SAVE button on the top of page. Factor 1. To input Factor 1, social roles and relationship problems, the user should click the Add New Problem button, on lower right side of page. A pop up screen will appear that includes a pull down menu for Social Role Categories. The category of social role functioning must be entered before selecting the specific role and problem type. The Social Role categories include: 1) Family, 2) Interpersonal, 3) Occupational, and (4) Special Life Situation. Once this category is chosen, the user chooses the specific social role. For example, under Interpersonal, the user might choose one of the following social roles: lover, friend, neighbor, member and other. After selecting the specific role, the user then chooses a specific Problem Descriptor. These include the following: abuse of power, ambivalence, responsibility, dependency, loss, isolation, oppressed, mixed and “other:” category. Users not familiar with these descriptors should read the New to PIE section or click on “more about problems” which will open a new screen that provides an explanation of each of these descriptors. For each social role problem there are pull-down menus to select the Severity and Duration of the problem as well as pull down menus for selecting the client Coping Abilities and Priority of the problem. After completing this, the user/practitioner would then enter the Goal(s), Recommended Intervention(s) and expected outcome for each social role problem identified. Users may enter as many problems in social roles as relevant for your client. It is common for clients to have difficulties in a number of categories of social roles. For example, clients may experience difficulties with various family members as well as occupational difficulties and/or difficulties with friendships. When done click the SAVE button on the top of page. Factor 2. -- Environmental and Social System Problems. As noted in New to PIE, Factor 2 describes the social systems and social institutions that impede clients’ social functioning; these comprise six categories of social institutions/social support system problems: Basic Needs Health and Safety Education & Training Voluntary Groups Judicial and Legal Affectional Support Groups Some of above categories of social institution problems have subcategories while other do not have subcategories. For example, under basic needs, the user might choose one of the subcategories: Food, Shelter, Employment, Economic Resources or Transportation. Again, more than one problem may be selected, but for each one selected the user must click the button, Add New Problem. A pop up screen will appear that includes a pull down menus for the specific problem type. For example, if Food/Nutrition is chosen, the user then may select type of problem from the pull down menu such as “Lack of food supply.” Similarly, if the user chooses, Education and Training problems, there are no subcategories. The user would 2 then choose Education and Training, click Add New Problem and choose from fhe pull down menu the category that best best describes the problem types, for example, “Lack of Educational facilities.” Again, for each problem or diagnosis noted, the user would indicate through pull down menus the Severity, Duration, Coping Ability, and Priority. Goal(s), Recommended Intervention(s) and Expected Outcome for each problem are then entered. When done click the SAVE button on the top of page. Factor 3: Mental Health Functioning -- Factor 3 should be completed if the client has a Mental Health problem. If the client does not have a mental health problem, the practitioner may indicate this by checking the box, No Mental Health Problem. Alternatively, the box Possible MH Problem, No Professional Diagnosis may be checked If the client appears to have a mental health problem, but there has not been a professional mental health diagnosis and the practitioner is not qualified to provide a diagnosis. There is also an option for Client Denies MH Problem. To enter a DSM 5 diagnosis, click the button, Add New Problem. The CompuPIE software provides pull-down menus for selecting any DSM 5 Mental Health diagnosis. The user may begin by typing in several key letters and a number of options will come up. For example, if the practitioner, types in “depress” numerous options such as Adjustment disorder with depressed mood, Alcohol-induced depressive disorder, Bipolar I disorder, Major Depressive Disorder, as well as others related to depression will appear giving the practitioner some options to consider. After entering the diagnosis, the practitioner may type the specifier, if any. Practitioner should then specify using the pull down menu Diagnostic Source and choose whether the diagnosis is Client Report or Professional Diagnosis. Additionally, through pull down menus, the practitioner specifies the Severity, Duration, Coping Ability, and Priority as well as Goal(s), Recommended Intervention(s) and Expected Outcome for each mental health problem. When done click the SAVE button on the top of page. Mental Status Exam MSE --- In addition to entering the DSM 5 mental health diagnosis, the practitioner may complete a Mental Health Status Exam (MSE). CompuPIE provides a checklist for the various components of the Mental Status Exam. 1. Appearance 2. Speech 3. Eye Contact 4. Motor Activity 5. Behavior 6. Mood 7. Affect 8. Perception 9. Orientation 10. Cognition 11. Insight 12. Judgment 13. Impulse Control 14. Thought Process 15. Thought Content 16. Self-Harming Behaviors 17. Risk of Suicide 18. Risk of Homicide 3 When done click the SAVE button on the top of page. Factor 4: Physical Health Conditions - Factor 4 should be completed if the client has a physical health problem. CompuPIE uses the International Classification of Diseases, 10th Revision Codes (ICD-10-CM), which is a system used by healthcare providers to classify and code all diagnoses. The CompuPIE software provides pull-down menus for selecting any ICD-10-CM code. If the client has a physical health problem, the practitioner should check Add New Problem. The user may then begin by typing in several key letters and a number of options will come up. For example, if the practitioner, types migraine, several options will pop up such as Migraine, classical (with aura); Migraine, common; and Migraine, unspecified. The practitioner then chooses the one that best describes the client’s condition. Practitioner then specifies Diagnostic Source and chooses whether the diagnosis is Client Report or Professional diagnosis. Again, through pull down menus, the practitioner specifies the Severity, Duration, Coping Ability, and Priority. Goal(s), Recommended Intervention(s) and Expected Outcome for each physical health problem are then entered. When done click the SAVE button on the top of page. Strengths and Resources -- Various social support strengths, environmental resources, mental health strengths and physical health strengths may be identified by checking relevant boxes. Additional Comments-- CompuPIE software provides space for augmenting the assessment. Report -- CompuPIE provides a printable comprehensive assessment of clients’ biopsychosocial functioning in a succinct format. The practitioner can choose to print either the long or short format. A client may be given a copy of the assessment form and together both practitioner and client can review the task of planning interventions and setting priorities. Open Existing Case --- Assessments may be updated or amended as the practitioner gains further information about client problems and strengths. CompuPIE software allows the user/practitioner to edit or amend this assessment, add follow-up or progress notes, conduct a re-assessment, and complete an ending or termination summary. Cases not needed may be deleted. To open an existing case click the button, Open Existing Case, then click the Search button and all entered cases will appear and may be sorted by id number, last, first and middle names. There are 5 options to choose: 1) Open/edit; 2) Write a follow-up note; 3) Conduct a re-assessment; 4) Close case / write a closing summary; and 5) Delete case. Open/edit allows the practitioner/user to view and/or edit the initial assessment. When edits or changes are needed, the practitioner/user should indicate that he/she is editing the assessment by clicking the Edit button; use the Save button to save any changes that are made. When the initial assessment is edited, a new date is noted and the updated assessment replaces the original initial assessment. Follow-up note allows the practitioner/user to write a progress note as well as note any changes on the 4 PIE Factors. Each follow-up note is saved by date and no changes are made to the original initial assessment, i.e., both are saved and can be later accessed and printed. Re-assessment allows the practitioner/user to conduct a full PIE re-assessment of the client using the 4 Factors, the MSE and the client strengths and resources page. Re-assessments may be saved or printed and later accessed along with the initial assessment and any follow up notes. 4 Close Case allows the practitioner/user to write a closing summary of the case, noting client progress on the 4 factors. Closing summaries are dated and saved and become part of the client record. 5
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