Service Note Completion

Although entering and completed service notes is the biggest and most important aspect of the process, the OnTarget mobile application provides a smooth workflow to ensure users are provided the most efficient manner to prevent the need for surfing through several screens. Because a service note is driven by the date(s) and time(s) in which a service is provided, starting a note is directly tied into the schedule process.

Within each schedule card, a Start Note button is provided for users to utilize when it’s time to begin entering data for a service note. The availability of the start note button becomes available is dependent upon the type of service assigned to the scheduled shift, the type of time of the scheduled shift (duration vs. start / end time), and the time in which the scheduled shift is to occur. Additionally, the process in which the time is entered for a service note differs depending on the type of service assigned to the scheduled shift.

The differences outlined below provide an abridged description of when the start note button becomes available. These will be explained in more detail later in this training guide.

1. Services that are associated with EVV requirements will require the user to clock in for a shift before the ability to start a service note is provided to the user. Once a user has clocked in

2. A scheduled shift that contains a duration type of schedule (not a start time / end time schedule) will provide the ability to start a service note on the date in which the shift is scheduled.
3. A scheduled shift that contains a start / end time type of schedule will provide the ability to start a service note based on the date and time of the scheduled shift.
4. Multi-day scheduled services will contain the Start Note button for the user to utilize to initiate data entry.

The differences outlined below provide an abridged description of when users enter time. These will be explained in more detail later in this training guide.

1. A service that requires an EVV driven clock in and clock out process requires users to clock in before a note can be started.This means that time entry must occur before the service cannot be started.However, clocking out for a shift driven by EVV requirements may occur at anytime during the shift.
2. Time entry for a scheduled shift that is not driven by EVV requirements occurs after the service note has been completed.

Viewing Service Note Data

The moment a user clocks in for an EVV related scheduled shift, the associated service note may be started. Within the OnTarget mobile application, this is indicated by the Start Note button turning from Gray to Green. Clicking this button initiates the process for entering collected data for all the outcomes associated to the scheduled service.

As stated previously, scheduled shifts that are not related to an EVV type of service, will not require a clock in and / or clock out. In these cases, the Start Note button becomes available at the date and / or time the scheduled shift starts.

To provide an organized manner for which the goals and outcomes are presented to the user, each goal is listed within the mobile application as a title highlighted in purple. The goal title can be expanded or contracted. Using the down arrow will expand the goal to display all associated outcomes. The outcomes are the specific tasks in which the user is expected to run / perform with the client.

Likewise, the goal title may be contracted to hide all the associated outcomes by clicking the up arrow located within the purple title.

Please Note: The purple goal title is displayed based on the configurations of your company. The title will show if configured to display. If not configured, the purple title will display blank, and the outcomes would be listed below. Please contact your company support for additional information.

The number of outcomes listed for each goal title is different for each service and each client. It may be necessary to scroll down / up the mobile application window to view all the associated outcomes. Each outcome that’s listed contains the following components:

1. Outcome Completion Indicator – Initially this appears as a small, blank circle located to the left of the outcome. Once the data has been entered for the listed outcome and saved, the circle will turn green and contain a white check mark. This indicates that the outcome has been completed.
2. Outcome Description – The description provides a portion of the outcome to be run / performed with the client during the scheduled shift. In many cases, the description may not fully show if the text is long.
3. Selection Arrow – Each outcome contains a right arrow on the right side. This is used to proceed to the next step of the data collection entry process. This provides the user with detailed information and functionality to record the necessary data for the listed outcome.

Entering Service Note Data

Once an outcome is selected from the provided list, the specific details are displayed for the user to enter the required and / or recommended data. Each outcome is written to specifically address the overall goal for the person served. And the specific way in which the data is entered varies from outcome to outcome.

Service notes that are associated with a grid type of style are configured to provide the ability to enter interventions, assessments,comments, or a combination of all three. Additionally, there are variations in how data is successfully entered and completed within the noted areas.

Interventions

Interventions are utilized within outcomes to indicate the needed assistance when running and completing the outcome. A set of interventions may include but are not limited to Independent, Verbal, Physical Assistance, etc. and the type of data entered for each may vary depending on your company’s needs.

The screenshot above shows a portion of the outcome detail for users to enter data.

1. Outcome Description – Identifies the specific details of the outcome providing basic instructions on the action to be taken when working on the outcome and how to measure the result of the outcome.
2. View Methodology – When clicking the View Methodology button, a pop-up window will display specific steps needed to perform and complete the listed outcome. A screenshot of a sample methodology is below.
3. Intervention with Toggle – Some interventions will contain a toggle that can be turned on or turned off. An intervention with a toggle indicates basic selection. In some cases, using a toggle for an outcome may result in the other listed interventions as unavailable.
4. Intervention with Value Entry – Based on the need of the outcome, some interventions may require a value entry. Typically,there are number based entries. The plus symbol used to the right of the number is used to increase the numeric value by one. The minus symbol to the left of the number is used to decrease the numeric value by one.

Please Note: The above screenshot is a sample of a set of interventions for the selected outcome and may not represent the configurations for your company and person served.

Please Note: Based on your company’s configurations,an outcome may only allow for 1 intervention entry. If this is the case, when an intervention is selected, the other remaining interventions will become unavailable. In these cases, updating an intervention entry for an outcome will require the removal of the current intervention entry to be provided the ability to re-select an intervention entry.

When viewing the Methodology, a detailed set of steps or information is provided to assist the user with performing the outcome with the person served. Very detailed methodologies may require the user to scroll down to view all the information. Choosing the Cancel or Confirm buttons will close the pop-up window.

Assessments

Assessments are utilized to provide data on the result of completing an outcome. The data entered for an assessment may be related to an intervention or the assessment may stand alone as the only required data entry.

For some outcomes, the assessment may be automatically entered based on intervention data entered for the outcome. Automatic assessments are based on configured rules for selected interventions created for each outcome. The use of automatic assessments may vary depending on your company’s needs or the needs of the person served.

Comments

The entry of a comment is available for each outcome and does not contain any limitations. However, there may be instances where if a specific intervention and / or assessment entered then a comment entry is required.

The screenshot provided above represents the view of the associated assessments for the outcome. The assessments are marked by a checkbox. Clicking or touching the checkbox completes the data entry for the assessments. Remember, some outcomes are equipped with configured rules that will automatically mark the appropriate assessment value. If you have additional questions regarding marking the appropriate assessment value, please contact your supervisor.

The comments section is available for each outcome and required entry is conditional on the selected intervention and / or assessment.These vary based on your company’s configuration.

Additional Text Entry

In some cases, outcomes or types of goal may outfitted with additional text entry fields. These are special fields that are configured based on the needs of your company and / or person served.

Completing or Updating Outcomes

Once the data entry is completed for each outcome, which may include intervention(s), assessment(s), and additional comments, the outcome is complete. As a verification that the outcome has been completed, clicking /touching a ‘Complete Goal’ button will scan the outcome to ensure entry. If the outcome is missing required data, the outcome will not save, and a message appears notifying the user of the needed entry.

Any time an outcome has been completed, if returning to the completed outcome to update or change any of the entered data, utilizing an‘Update Goal’ button will save the outcome update entry. The ‘Update Goal’ button is displayed to signify to the user that the outcome was originally saved with entered data in the event a user selected an incorrect outcome.

The ‘Complete Goal’ and ‘Update Goal’ buttons are located at the bottom of each outcome after all data entry points.

Completing a Note

The process for completing a note occurs when all outcomes have been addressed resulting in a green check indicator for each of the listed outcomes and a ‘Confirm Time’ button is available at the close of the outcomes list. Any outcome that does not contain a green check mark indicates that additional data entry may be needed to complete the outcome.

Clicking the ‘Confirm Time’ button directs the user to the process in which either the start time and end time are newly entered, or the start time and end time captured during a clock in / clock out may be edited. The ‘Confirm Time’ process differs slightly based on the type of service provided and the schedule type.

Confirm Time Page

The confirm time page contains the data elements needed for users to review, edit, and confirm the service time provided. Again, based on the type of service provided, there may be additional data entry points required for entry. These additional data entry points will be explained later in this document.

1. Date of Service – Provided to the user to ensure the correct date of service is selected / displayed.
2. Service Start and End Times – The start and end times will display based on the service type provided and / or the schedule type. For a non-EVV scheduled service with start / end times, the times will display based on the schedule. For a non-EVV scheduled service for a duration,the start and end times will be blank requiring the user to manually enter the times. For an EVV related shift, the start and end times will display the clocked in / clocked out times.
3. AM / PM Slider – The AM / PM slider is used by the user to indicate the start / end times occurred in the AM or PM.This is a simple slide button in that clicking the button will change the slider.
4. Additional Service Information – Like the service date, this section provides the service information for the user to confirm the correct service is selected / displayed.
5. Sign Note – Once the time is entered,edited, and confirmed, the ‘Sign Note’ button begins the process to finalize the note by signing.

Confirming Time for Non-EVV Shifts with Start Time/ End Time Schedules

Because non-EVV scheduled shifts do not require a clock in when the service starts or a clock out when the service ends, the OnTarget mobile application pre-populates the scheduled start time and end time for the user to review,edit, and / or confirm.

If configured to do so, the user can freely edit the start time and end time to ensure that the correct service time is entered based on the provided shift.

Please Note: There are company specific rules that may provide allowances or prohibit start and end time entry. These may include the ability to edit the times as well as the amount of time before or after the scheduled time. Additionally, entered / edited start and end times should be done within 15-minute increments (i.e., 1:00, 1:15, 1:30, 1:45) rather than exact minute times.

Confirming Time for Non-EVV Shifts with Duration Schedules

Not all scheduled shifts may contain a scheduled start time and end time. Instead, the scheduled shift may contain the number of hours(duration) in which a service may be provided. In this case, the ‘Confirm Time’ page will not have the start and end times pre-populated. This type of scheduled shift will require the user to manually enter the start and end times into the OnTarget mobile application. The start time and end time entered should total the number or hours (duration) scheduled.

Please Note: There are company specific rules that may provide allowances or prohibit start and end time entry. These may include the ability to edit the times as well as the amount of time before or after the duration time. Additionally, entered / edited start and end times should be done within 15-minute increments (i.e., 1:00, 1:15, 1:30, 1:45) rather than exact minute times.

Confirming Time for Multi-Day Schedules

As a reminder, a multi-day schedule may contain one or more shifts that are associated with the same service note. Within OnTarget, the associated service note is configured to allow users to attach multiple shifts to the same note. This requires the shift to contain the same caregiver (user),same client, and the same service to be scheduled or provided on the same date.

Please Note: The Confirm Time button for multi-day service notes will be available for users to click even if all the outcomes are not addressed. This is to allow users the ability to complete a portion of the outcomes run during a specific shift then confirm time for that shift. The user can go back and complete the outcomes for the remaining shifts.

If a schedule contains one or more shifts and is associated with a multi-day service note, when the Start Button is clicked on the schedule card, OnTarget automatically applies all scheduled shifts that contain the same caregiver, same client, same service for the same date of service. This means that when the user confirms time for a multi-day service note, the time for each scheduled shift is listed for edit and / or confirmation.

Each shift card contains scheduled time information for each shift. If the shift contains a start time and end time, the card will contain that scheduled time. However, if the shift contains a scheduled duration, the Time displayed will be the total number / duration of hours scheduled.

Users can expand or contract the shift card to reveal entry fields for the start time and end time. These fields can be used to enter a start time and end time for a scheduled duration shift or edit the scheduled time for a start time / end time shift. Of course, if the scheduled start time and end time do not need edited or updated, the user does not need to make a manual entry.

Unlike service notes that are non-multi day, an Update Shifts button is available for users to utilize once shift time is entered or edited. The purpose of this button is to allow a user to update one or more times to confirm without having to sign the service note. Users who are entering outcome data and confirming time per shift as they occur can use the Update Shifts button to ensure their time is recorded and sign the note later after the last scheduled shift ends.

Please Note: Scheduled duration shift cards must contain a start time and end time before the service note is signed. The start time and end time for these types for shifts will remain blank until entered,updated and / or signed.

In addition to entering or editing the shift time to Update Shifts, users are provided the ability to cancel a listed shift from the Confirm Time page. The process is very similar to cancelling a shift from the schedule except that only one shift is cancelled at a time on this page. Once a shift card is expanded, the button containing 3 dots can be clicked to initiate the cancelling of the selected shift. The user is provided the ability to enter a cancel (Missed) shift reason as well as a comment. Clicking the Cancel Shift button on the cancel shift page removes the shift.

Please Note: If all scheduled shift cards are cancelled from the Confirm Time page, the created note will be deleted from OnTarget as it is no longer valid. If the user mistakenly cancels all shifts and the note is deleted, the cancelled shift(s) will need to be adjusted and anew note created.

Please Note: The Sign Note button on the Confirm Time page for a multi-day service note will perform the functions for both updating the note and signing the note. There is no requirement for a user to click Update Shifts to sign the note.

Confirming Time for an EVV Shift

Remember, EVV related scheduled shifts will require a clock in / out process. This is a requirement for both start / end time scheduled shifts and duration scheduled shifts. At minimum, users are required to clock in before starting the process for service note entry which may result in slight differences during the confirm time process.

Confirming Clocked In and Clocked Out for an EVV Shift

When confirming time for an EVV shift in which the user has clocked in and clocked out using the buttons from the schedule, the start time and end time will pre-populate. Understanding that there may be instances where a user may have clocked in or clocked out late, the OnTarget mobile application provides the ability to edit the clock in and clock out time when confirming time. However, editing the times for an EVV shift requires additional information to be entered.

Any time the time is edited for an EVV related shift, an Action and Reason are required. Within the OnTarget mobile application, a drop-down set of values is provided for users to select a predetermined action and reason.

1.      Reason – This additional data entry is used to describe the reason the time is being edited.

2.      Action – The action entry provides a description as to what was done to that resulted in the reason the time required edit.

Please Note: The Reason and Action drop down list is preconfigured and meets the required expected information for EVV regulations. Please contact your supervisor if you have questions on the drop-down list provided.

Confirming Time for a Clocked In Only EVV Shift

Because users can clock in for a scheduled EVV shift and start the service note without clocking out from the schedule page, entering the end time when confirming time is required. Typically, this occurs if a user misses the time in which the clock out should have occurred. When confirming time in this case will result in a 00:00 pre-populated time for the end time.

Manually entering the clock out time for an EVV scheduled shift requires the user to select a Reason and Action.

Please Note: Users that miss the clock in and clock out time for a scheduled EVV shift must utilize the Edit Time button from the schedule to manually enter the start time and end time along with a Reason and Action code. Please refer to the Schedule section for additional information.

Signing the Service Note

Signing a service note is the last step in the note entry process and confirms that all data entered from the time to the interventions and assessments are correct and ready for submission. Submission of the service note begins the OnTarget process for approving the note to prepare for the remittance of payment for service(s) provided.

The ‘Sign Note’ process is a quick, easy process but may differ based on the requirements configured by your company. A portion of the sign note process reviews the user’s record within OnTarget to ensure that all the requirements are met. For example, in many cases a major requirement to a user’s record within OnTarget is training. And, in many cases, if a training is expired but required to provide a service, the user may be prohibited from signing a service note. OnTarget validates the requirements when service notes are signed. If any validations fail, they are listed for the user to review. Of course, if all validations pass, the sign note process completes without issue.

Signing a service note requires the user to enter their OnTarget mobile application password to attest an electronic signature.Clicking the ‘Confirm’ button finalizes the password entry to sign.

Overriding Validations

Users with failed validations may be provided the option to override the detected validation warnings to continue successfully signing the service note. Within the OnTarget mobile application, if a user can override detected validations a warning message will be displayed and provide the user the option to either continue signing or halt the process of signing the service note.

Keep in mind, however, that not all detected validations failures may be overridden. Any validations that cannot be overridden results in the user prohibition of signing the service note. The user is not provided with the option within the OnTarget mobile application to override. If this occurs, the user should contact their supervisor as soon as possible.

Please Note: Validations are configurable within OnTarget and differ for each company. This is the same for validation overrides. Please contact your supervisor for additional information on the configured validations and ability to override for your company.

Steps to Complete a non-EVV Service Note from the Schedule

1. Locate the scheduled shift within your schedule.
2. Click on the Start Note button.
3. Click each listed outcome and enter the appropriate intervention and / or assessment values.
4. Complete any required additional comments if necessary.
5. Once all outcomes are completed, click the Confirm Time button.
6. Enter the Start Time and End Time for the scheduled service / service time provided.
7. Click Sign Note
8. Enter your OnTarget mobile application password.
9. Click Confirm.

Steps to Complete an EVV Service Note from the Schedule

1. Clock in for the scheduled EVV shift.
2. Click Start Note (It is not necessary to clock out before starting the note).
3. Click each listed outcome and enter the appropriate intervention and / or assessment values.
4. Complete any required additional comments if necessary.
5. Once all outcomes are completed, click the Confirm Time button.
6. Verify and confirm the Start Time (time clocked in) and End Time (time clocked out). Please Note: if not clocked out, you must manually enter the clock out time.
7. If editing the Start Time or End Time, select a Reason and Action code from the provided drop-down menus.
8. Click Sign Note
9. Enter your OnTarget mobile application password.
10. Click Confirm.