Clinical (PIE) Notes

Configurations for a Clinical (PIE) Note

The OnTarget mobile application provides users the ability to enter service note data for different types / styles of notes. The first type of service note outlined within this document, a grid note, is vastly different than the clinical note type.

Often referred to as a PIE note, data for a Clinical note requires users to enter information into text fields rather than selecting an intervention and assessment value. PIE notes often include lengthy data entry into several fields.

Associated Clinical (PIE) Note Configurations

OnTarget provides customers the ability to set configurations associated to PIE notes that determine data entry requirements, entry availability, drop-down values, and custom field labels. Below are the OnTarget configurations associated with PIE notes and information on utilizing the settings.

Purpose of Contact Selection Only

(Configure > List Configuration > Notes > Rules> Purpose of Contact Selection Only)

Depending on the setting for this configuration, users are providing the ability to only select pre-written goals from a drop-down list to automatically enter in a field or provide users the ability to select a pre-written goal from a drop-down list and / or manually enter data directly into the field. Setting this configuration requires users to mark or unmark a checkbox.

1.     A marked checkbox results in users being provided the ability to select pre-written goals from a drop-down list only.Direct text entry into the field is not available.

2.     An unmarked checkbox results in users being provided the ability to select pre-written goals from a drop-down list, entry text directly into the field, or both.

PIE Note Mandatory

(Configure > List Configuration > Notes > Rules> PIE Notes Mandatory)

This configuration determines if all the standard PIE note fields require entry or if none of the standard PIE note fields require entry.The standard PIE note fields include Contact Type, Location of Service, Purpose of Contact, Intervention, and Effectiveness.

1.     A marked checkbox for this configuration will require users to enter data for all standard PIE note fields.

2.     An unmarked checkbox does not require users to enter data into any standard PIE note fields.

Enable Location for Notes

(Configure > List Configuration > Billing > Rules> Enable Locations for Notes)

By default, OnTarget provides a set of standard drop-down values for the Location of Service field within a PIE note. These values are OnTarget standard and cannot be changed. However, this configuration provides users the ability to select from a custom list of values in the drop-down menu for Location of Service.

1.     A marked checkbox results in the custom drop-down value list being display for users to select with entering PIE note service data.

2.     An unmarked checkbox provides users with the standard OnTarget drop-down values for the Service Location field.

The custom list is entered within OnTarget configurations located in Configure > List Configuration > Billing > Service Locations. The values / entries within this configuration will be displayed in the drop-down list for the Location of Service field.

Custom Labels

(Configure > List Configuration > Notes > Custom Labels)

Custom labels provide users the ability to rename the field labels for the standard PIE note fields. For example, using the custom fields functionality within OnTarget, users can change the field label / name from Purpose of Contact to Purpose of Visit.

Configured custom labels for PIE notes will result in the mobile application displaying the field name changes. The custom labels are also applied to the service note within OnTarget desktop.

Starting a PIE Note and Entering Data

The process for starting a PIE note is the same as grid notes. Clicking the Start Note or Continue Note button from the mobile application Schedule, Notes, or Action Center pages initiates the data entry process.

Unlike grid notes, the process of entering data for a PIE note within the mobile application is a step process. The steps direct the user through the data entry for a PIE note according to the organization of the fields. The step process results in data entry safeguards as well as additional benefits:

1.     Ensures that data entry is saved for each step as the user progresses to avoid data loss if disconnection occurs.

2.     Provides users 1 screen per step to avoid scrolling lengthy pages to enter text data.

3.     Retains an organized, consistent data entry for PIE notes.

The PIE note data entry process within the mobile application is outlined below. These steps will be covered in more detail later in this section.

1.     Step 1: Entry of the Type of Contact and Location of Service.

2.     Step 2: Selection of pre-written goals and / or manual text entry for Purpose of Contact.

3.     Step 3: Data entry for Interventions.

4.     Step 4: Data entry for Effectiveness.

5.     Step 5: This is situational. PIE notes that are configured to include Custom Fields will appear in this step for users to enter data. If not, Custom Fields are configured, Step 5 is not available.

Within each step, the mobile application provides users the ability to move forward to the next step and saves data entry using a Next button or move backwards to the previous step by using a Previous button. This ensures that users can easily move back and forth between steps to complete the PIE note effectively.

In addition to the Next and Previous buttons, the PIE note navigation includes indicator bars for each step. These provide visual representations of complete or incomplete PIE note fields relative to requirements as well as indicate to users their current step. Please see below for an in-depth description for each bar color and what they represent.

1.     Gray Bar – Indicates a PIE note step in which a user has not progressed to for data entry.

2.     Blue Bar – Indicates the current PIE note step in which the user is viewing.

3.     Green Bar – Indicates that all required PIE notes fields have been completed for the corresponding step. Please Note:If PIE note fields are configured as NOT required, the green bar will be displayed even if PIE note fields are empty.

4.     Red Bar – Indicates that a field within the corresponding PIE note step does not contain data and the PIE note field is required. Please Note: If PIE note fields are NOT required and fields do not contain data, the red bar will not display. A green bar will be displayed.

PIE Note Data Entry Step 1

The first step of the PIE note data entry process consists of two fields associated with drop-down values for users to select for entry.

1.     The Type of Contact field is outfitted with an OnTarget standard drop-down list of values in which the user can select.

2.     The Service Location field, like the Type of Contact field, provides users with a drop-down list of values to select. This list may contain the OnTarget standard drop-down list of values or if configured, displays a custom list of values.

PIE Note Data Entry Step 2

The data entry for Purpose of Contact is step 2 for PIE note data entry and is comprised of 2 fields for the user to utilize.

1.     The top field beneath the Purpose of Contact field label consists of a drop-down list of pre-written Long-Range Goals that are associated to the service for the PIE note.

2.     The field beneath the Description label is provided to contain automated data entry based on drop-down selections as well as manual text entry if configured.

When utilizing the Purpose of Contact field drop-down list of pre-written Long-Range Goals, selecting a goal marks a corresponding checkbox to indicate which goals had been selected. De-selecting a previously selected goal unmarks the checkbox. Additionally, once a Long-Range Goal is selected, the goal description is automatically copied / entered into the Purpose of Contact Description field. And, when de-selecting a selected goal automatically removes the data from the Purpose of Contact Description field.

If configured, users also can manually enter additional text into the Purpose of Contact Description field to accompany the selected,auto-entered Long-Range Goals. Although users can select a Long-Range Goal to auto-populate in the adjoining field, users may choose to manually enter text directly and not select a goal.

Please Note: Once a Long-Range Goal is selected from the drop-down list and is automatically added to the Description, if entering manual text into the field that is on the same line as the auto-entered changes the goal description and de-selection to remove the goal is not available.

PIE Note Data Entry Step 3

The third step of data entry for a PIE note involves manual text entry into the Intervention field. Initially, the field appears as a single line entry field. However, as users type into the field, automatic expansion of the field occurs as the user types. There is no character limit when entering data into this field.

Please Note: Users may have the ability to utilize their mobile device’s speech to text functionality for entering data into this field. This is not a native mobile application function but rather a potential coordination between the OnTarget mobile application and user mobile devices.This may not function for all mobile devices and OnTarget is unable to support user’s native functionality for mobile devices.

PIE Note Data Entry Step 4

The third step operates / functions the same as Step 2. The Effectiveness field is contained in this step and is a manual text entry field.

PIE Note Data Entry Step 5

Step 5 for PIE note data entry is situational in that this if the service note is not associated with configured custom fields, then Step5 is excluded. However, if the service note is associated with custom fields,then the fields are listed within step 5.

Custom fields can be configured to display within the service note header, body, or footer. Within Step 5, custom fields are ordered and displayed based on the area configured. Fields configured for header are displayed first, body second, and footer third.

Custom fields may also be configured to require data entry.The OnTarget mobile application validates data entry for custom fields and will display a message if a required custom field does not contain data. Please Note: Required custom fields should contain data entry even if the standard PIE note fields do not require entry.

Finalizing a PIE Note – Required Fields

When users reach the last step for PIE note data entry, a Confirm Time button is available in place of the Next button. The step in which the Confirm Time button is displayed is dependent on the service note’s associated custom fields.

1.     PIE notes that are associated with custom fields will contain the fields in Step 1 or Step 5 in which the Confirm Time button is listed on the bottom right. The step in which the custom field is displayed is dependent on the area the custom field is configured to display (header, body, or footer).

Within the mobile application the completion of a Clinical (PIE) note is presented to users as a step-by-step wizard, guiding users through each section of the note.

Users can proceed to the next step of the note entry process even if they have not completed all required header custom field data. However,if a header custom field is mandatory, OnTarget will highlight the step indicator in red, as well as emphasize the required field, to ensure user awareness. Please note that users will not be able to sign the service note until all required fields are completed.

The body and footer custom fields will continue to be accessible in the final step of the note entry process. Similar to the required header custom fields, users will be alerted to any missing data in the required fields before they can sign the service note.

2.     PIE notes that are not associated with custom fields will NOT contain a Step 5 resulting in the Confirm Time button listing on Step 4.

Utilizing the Confirm Time button saves the data entry for the last step and directs the user to the Sign Note page. This process includes running validations on data entered for required fields (both PIE note fields and / or custom fields). Required fields for PIE notes are validation when clicking the Confirm Time button while validations for required custom field data entry occurs when clicking Confirm Time (for single time notes) and when clicking Sign Note (for notes with multiple times).

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 page for a service note is outfitted with specific information regarding the completed note. This page also provides the user the ability to enter, edit, and verify the start time, end time, or total duration. This includes confirming time for service notes associated with EVV services.

Signing a PIE Note

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.