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Treatment for substance abuse is complex, and using a comprehensive substance abuse assessment helps clinicians create an effective treatment plan. Behavioral health professionals complete a substance abuse assessment on each new client to help understand their unique needs and concerns.

Substance abuse assessments can include gathering detailed information on a patient’s drug use, psychosocial history, and medical history. It is an essential part of treatment and care and is used to develop the client’s overall treatment plan. 

Each treatment plan is individualized, and proper documentation of that plan ensures that multiple behavioral health providers can implement the plan and evaluate client progress. EHR systems capture assessments and treatment plans in a centralized digital hub, providing a more effective and efficient experience for the client and their care team.  Additional benefits of EHR software for substance abuse treatment planning and documentation include: 

  • Reduced administrative burden 
  • Improved chart accuracy 
  • Enhanced collaboration among treatment providers 

Reducing Administrative Burden With Your Substance Abuse EHR 

When a client arrives for an intake assessment, numerous forms must be completed, which can quickly create additional work for the operations staff. When using substance abuse EHR software, care operations are automated, so valuable time is saved in areas like signatures and approval, data storage, records accessibility, and billing. This allows both the operations staff and providers to save time and stress as they seamlessly transition between forms, case notes, and tasks on one platform, from any device. 

Decreasing Errors Within Your Substance Abuse Treatment Plan 

A clinician’s substance abuse treatment plan guides the course of each client's therapeutic program, ensuring personalized care and the best chance of achieving positive outcomes. Treatment plans should be evidence-based and involve the client's support system and mental health providers. As such, the plan must be well documented so that it can be easily  shared and understood by all parties. Common documentation challenges faced by substance abuse agencies include:  

  • Manual data entry which can result in errors 
  • Paper documentation that is tough to track and keep top of mind 
  • Potential for HIPAA violations

These documentation challenges lead to potential errors, miscommunication, and delayed or lost billing reimbursements. Some errors can even result in fines. 

Inadequate documentation can lead to poor coordination of care and hinder the overall treatment process. This can worsen client outcomes and lead to unorganized and inconsistent standards of care. This is particularly important because substance abuse treatment typically involves multiple providers. If providers are not working together to coordinate care within the substance abuse treatment plan, or at least provide care that complements the plan, the client may experience decreased quality of care.  

Substance Abuse EHR Software Enhances Treatment Planning

The best solution to streamlining treatment plan documentation has been the introduction of electronic health records (EHR) software in the behavioral health field. Not only does it streamline data entry, but the data is more accessible to all parties, easy to share, and available in real time from any device.

Healthcare agencies were quick to adopt EHR software due to financial incentives from the Centers for Medicare & Medicaid Services (CMS) and the HITECH Act of 2009. However, many mental health care providers still do not use EHR solutions. Today's HIPAA privacy regulations allow information to be shared amongst providers while maintaining the client's privacy outside of the healthcare system. Substance abuse EHR software, like Exym, makes it easy for care teams to securely share client information while maintaining strict HIPAA standards.

Today's substance abuse agencies are encouraged to use EHR software to enhance treatment plan documentation. This is for the benefit of the provider, client, and any subsequent providers the client may have. Electronic health records simplify the information sharing process and ensure that clients receiving substance abuse treatment have detailed health history and treatment records, which in turn helps providers quickly establish a continuum of care.

What to Look for in a Substance Abuse EHR

Key features and functionalities of substance abuse EHR systems include:  

Substance-Abuse-EHR-Exym (1)

A quality EHR system, such as Exym, will also link notes to appropriate billing codes, so that a client's diagnosis and billing remains consistent during the progression of the treatment plan. Because substance use disorder ICD 10 codes provide a universal language for documentation purposes, they are the key to creating documents with clear diagnostic criteria and a path forward for documentation and billing. This substance abuse EHR feature is instrumental in substance use care from a clinical and financial standpoint.  

Because substance abuse care, and healthcare in general, is filled with a complex lexicon, there are many ways to describe similar conditions. ICD 10 codes reduce ambiguity and allow all members of a care team to use the same language. Substance abuse EHR systems facilitate the use of that language, so it is not cumbersome or foreign to the software user.  

Additionally, with the right software, information is shared securely with other providers, so the administrative burden of care coordination is diminished. When all data is digital, errors are lessened, legibility is improved, and records are more clear and easy to use. Appointment scheduling, treatment plans, and claims management are all accessible from one platform, which can be accessed from any device.

With EHR software the entire treatment team can access the same information from a standardized source, regardless of whether the client is receiving care from multiple providers. Care is streamlined and records follow the client, so there are no preventable gaps in care. Substance abuse EHR software allows team members to easily communicate and share the same substance abuse treatment plan, which ultimately benefits the client and providers.

Exym for Substance Use Providers

If you are interested in substance abuse EHR software take a look at our website page for Substance Abuse Providers, and request a demo of Exym today.  

Exym is a comprehensive EHR software solution designed specifically for behavioral health agencies. Trusted for 20+ years, our intuitive and customizable software empowers providers to improve client outcomes, manage revenue cycles, and increase agency efficiency. Exym allows you to spend more time on what matters most- the clients in your care.

Lisa Potter
Post by Lisa Potter
September 13, 2023