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Clinical Note/Documentation FAQ
Q: I need to create one note with multiple time entries. How do I do that?
A: In order to create a single note with multiple time entries, the note must be created using a template with the “Multi-Day’ function enabled. Note templates are configured by going to Configure > Services > Note Templates. The “Multi-Day” field should be set to “Yes” for the template in order to enable this functionality. This template should then be linked as the default for the service being documented by going to Billing > Services > Note Configuration > State Service > ‘Default Template’ drop-down. Note: multi-day note templates should not be used for documentation of EVV required services.
Q: How do I print a note from OnTarget?
A: From the Notes desktop search grid, apply filters to ‘drill down’ to the note(s) to be printed. Click ‘Search’ to refresh the search grid. Once the note(s) are in view, click on the ‘Print Notes’ button at the bottom of the search grid. This will generate a .pdf file that can be opened, saved, and/or printed.
Q: I have created my note, but one of the goals that displays is not correct. How do I get this fixed?
A: Once a note has been saved (showing as ‘Work in Process’), the goals that synced to that saved instance of the note cannot be changed. Notify a supervisor of the issue and wait for confirmation that the issue has been fixed. Then, delete the saved note (as long as it has not been signed) and create a brand new note. This will ensure that any corrections that have been made to the treatment plan goals/outcomes will sync to the newly created note.
Q: I have created a note in error, but the system will not let me delete it. What can I do?
A: If the note has not been signed, it can be deleted from the Notes Desktop by selecting the red trashcan icon next to the client name for the note to be deleted. If the note has been signed, the system will not allow the note to be deleted. Notes that have been signed, can be ‘zeroed out’ by clicking 'Retract", located on the bottom left of the note. The note must then be approved for blling and payroll to complete the retraction.
Q: I am able to open my note, but I can’t edit it. How do I make edits to my note?
A: First, verify that the note is showing as "Work In Process". This can be verified from the note workflow chart (right hand side of the note information screen). Only notes that are listed as "Work In Process" can be edited. If the note is listed as "Signed", then the note will need to be unsigned first, to make any edits. If the note is listed as "Approved", then a supervisor will need to unapprove the note first; then the note can be unsigned and edits made.
Q: How do I send a task that is relevant to a specific note?
A: First, open the note by either double-clicking on the note, or by clicking the ‘edit note’ icon. Once the note is open, click on the second tab from the left. This is the ‘Tasks’ tab. Click on ‘Add a SubTask’, update the ‘Assigned To’ drop-down to the intended recipient, enter a ‘Description’ for the task, and click on ‘Save’ to send the task. This task will now be visible (with ‘Note’ hyperlink) on the ‘My Tasks’ dashlet of both the task creator and recipient.
Q: When I print grid notes, the header displays “North Carolina Division of Mental Health/Developmental Disabilities/Substance Abuse Services”. How do I customize the note header display for grid notes printed out of OnTarget?
A: From Configure > List Configuration > Notes > Rules, deselect the ‘Use Default Grid Note Header’ checkbox. Next, enter the desired note header text for grid notes in the ‘Grid Note Header’ field, and Save.
Q: When I attempt to save a clinical (PIE) note, I am getting an error message that says “Error Saving – Please make sure all required fields are filled out/selected…”. I have checked the note, and it appears that I have completed the “P, I, and E” sections of the note; there are no custom fields on the note either. How do I successfully save my note?
A: This common error is often the result of missing Type of Contact and/or Service Location data on the note header. Ensure that the ‘Type of Contact’ and ‘Service Location’ fields have been completed, and then attempt to save the note once again.
Q: I have created a saved view from the Notes desktop called ‘Unsigned Notes’ that includes the ‘Caregiver Signature’ – ‘All Unsigned Notes’ combination. How do I allow other users to access this saved view?
A: In order to make the saved view ‘Global’, and thus available for use by other OnTarget users, click the ‘wrench’ icon close to the view selection drop-down from the Notes search grid. Once the ‘Edit Views’ dialog opens, find the saved view and select the ‘Global’ checkbox. The saved view can now be accessed by other OnTarget users.
Q: When I go to Notes, click +Add Note, enter the Client Name, Service Date, and select the Service, I am getting a message that says ‘You must select a schedule to add a note for this service’. How do I proceed with writing my note?
A: This error message means that the service being selected, requires a schedule for note completion. After the client name and service date have been selected, click on the ‘Schedule’ drop-down (upper right corner of note). Select the matching date/service, and then proceed with writing the note. If a schedule link does not appear in the ‘Schedule’ drop-down, or the correct date/service does not appear, a supervisor or scheduling manager should be contacted.
Q: I have opened a signed note from the Notes desktop that I want to approve, but when I go to ‘Process’, it is greyed out (not active). I know that I have supervisor rights and can approve notes. How do I get this note approved?
A: This scenario typically occurs when a user attempts to approve a note for which they are not showing as the ‘Supervisor’. To get the note approved, enable notes super-user mode by going to Options > Notes Super-user mode (checkbox). Next, return to the note, and the ‘Process’ button should be available for note approval completion. If ‘Note Super-user mode’ is not available but it should be, contact a supervisor.
Q: I attempted to ‘Bulk Approve Notes’ from the Notes search grid, but I received an error message that read ‘You are not the supervisor of one or more of the notes’ and ‘One or more of the selected notes do not have the same supervisor’. One of the notes I selected for bulk approval does have a different supervisor assigned, as this is a different service and program. But I still need to get all of these notes approved on my end. How do I do this?
A: This scenario typically occurs when a user attempts to bulk approve a series of notes for which they are not showing as the ‘Supervisor’, for all notes selected. To get all of the notes approved in bulk, enable notes super-user mode by going to Options > Notes Super-user mode (checkbox). Next, return to the notes search grid, re-select the notes if necessary, and click the ‘Bulk Approve Notes’ button again.
Q: When I write a grid note, the note keys are not showing up in the correct order from left to right. How do I get the grid to display the keys in the correct order?
A: The left to right ordering of Intervention and Assessment keys displayed on grid notes is configured under the note key configuration section in OnTarget. From Configure > List Configuration > Notes > Note Keys. The left to right ordering on the grid note, is analogous to the top to bottom sort ordering of the keys displayed. The order of key display can be changed here by left clicking any key and dragging/dropping to the desired location (indicated by the ‘Order’ number). Note: any changes made to the key order configuration, will not affect previously saved notes.
Q: As a supervisor who is approving notes, I am finding that there are notes with start and end times that deviate from schedule start and end times. Is there an easy way to find notes in the Notes search grid that have start and end times that differ from the linked schedule start and end times?
A: The easiest way to find/display notes from the Notes search grid that have start and end times that differ from the linked schedule start and end times is by using the ‘Deviates from Schedule’ filter. This filter can be found at the bottom left of the filter list from the Notes search grid. Set the ‘Deviates From Schedule’ filter to ‘Yes’, and click ‘Search’ to find notes with start and end times that differ from the linked schedule start and end times.
Q: While reviewing signed notes for approval, I have noticed that there are several objectives with ‘N/A’s selected, where ‘Comments’ have not been added. How can we ensure that staff are required to add comments, when the ‘N/A’ key is selected?
A: The ‘Require Comment’ for selected keys function, is configured under the note key configuration in OnTarget. From Configure > List Configuration > Notes > Note Keys. Locate the ‘N/A’ key(s) in the list, left click on the key, and select the ‘Require Comment’ checkbox. Save the change by clicking ‘Update’.
Q: When I search for notes at the Notes search grid, I notice that there is a column called ‘Actual Time Status’. Some of the notes have the corresponding checkbox selected. What does this mean, and can I do anything to pull the notes out of ‘Revision’?
A: A note may display with a ‘Revision’ status if it has been unapproved for billing and/or payroll. The corresponding time record (Time Records search grid) will be highlighted in blue. Typically, by reapproving the note for billing and/or payroll, the time record will change to a status of ‘Ok’. If a time change has been made on the note that impacts billing and/or payroll, an additional step of re-importing the note into time records is required to change to a status of ‘Ok’; using the ‘Create Time Records’ function from the Notes desktop.
Q: When I try to save a grid note in OnTarget, I am getting an error that states “There are no outcomes associated for this service and client. Please add outcomes to this client’s service from the client management screen”. I know that I have added outcomes to the client’s treatment plan. What is causing this error message to pop-up, and how can I resolve the issue?
A: This issue is commonly caused by selecting the wrong service for the outcome. For instance, the outcome may have service ‘MCO-G-H2015HQ’ selected, but the schedule/note are referencing service ‘MCO-H2015’. Ensure that the service code is correctly assigned at both the outcome, and the schedule and/or authorization. The service code must match in all of these places in OnTarget.
Q: I have created notes for 2 clients in OnTarget with the same date and same time. The services are setup as group services in OnTarget (overlapping times are allowed). However, when I attempt to sign these 2 notes, I get a warning that overlapping times are not allowed. How do I prevent the overlapping time warning, and proceed with signing these notes?
A: Ensure that the service codes being provided to these 2 clients are the same. If they are not, the system will validate the services as completely different; even though they may be marked as ‘group’. If the services are different, then an overlap service group will need to be configured. This can be setup from Billing > Services > Service Groupings > Overlap Service Groupings > Add Service Group. Name the service group, select the group services that should be included in the group, and click Save.
Q: Staff are reporting that they are unable to enter certain characters on keys for grid notes. For example, the caregiver is trying to enter a ‘Y’ for the ‘Refused’ assessment for the note. The assessment key will only allow the caregiver to enter an ‘X’. How do I adjust the note key configuration to allow staff to enter a ‘Y’ for ‘Refused’?
A: Update the Allowed Keys for the Refused key by going to Configure > List Configuration > Notes > Note Keys. Locate the key that needs to be updated, and add the value needed to the ‘Allowed Keys’ list. This is a dropdown menu where multiple options can be selected.
Q: I have a caregiver who is unable to complete their note, as the service drop-down displays ‘none’ when they go to add a note for the client. I have checked the service authorization for the client and verified that the service date range is current and correct. The client also has an updated treatment plan with current dates. What should I do next; how do I fix this issue?
A: Most likely, the cause of this issue is the configuration of a credential type that has been assigned to the caregiver’s employee profile. Start by checking the credential type of the employee by going to the Employee desktop > Demographics tab > Credential Type field (lower right of demographics window). If there is a credential type present, verify the services associated with the credential type by going to the Employee desktop > Credential Type (located at the top of the menu) > Select the associated credential type. Once services have been selected for the associated credential type, the services will populate on the note. Select the checkbox beside each service to add them to the credential type configuration.