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06 Creating a Clinical Note
Starting a Clinical Note
1. Click on the Notes desktop
2. Click on the Add Note button
3. Select the client from the drop-down
- Helpful Hint: If the system is being used to schedule services, then notes should be created from scheduled events.
4. Select the schedule from the drop-down (if applicable). This course will focus on creating clinical notes directly from the Notes desktop without a corresponding scheduled event.
- Helpful Hint: If the system is being used to schedule services, then notes should be created from scheduled events. While you can select a schedule from this drop-down, it is typically preferred to start creating your note from the scheduled event directly at the Scheduling desktop.
5. Select the authorized service.
- Note: once the service is selected, a corresponding Service Unit Utilization graph will appear to the right of the window.
- Helpful Hint: Only services with corresponding authorizations for the client selected will show up in this drop- down. Each service will also display a corresponding end date. Selecting the correct service provided is critical so that the corresponding goals for that service are displayed.
6. The template field should auto-populate based on the service selected. If the template you need differs from the template that auto-populates, a different one can be selected from the drop- down.
7. Enter the Start and End Times or the Duration for the note. Note: the requirement for start and end time or duration is preconfigured for each service.
- Helpful Hint: Only services with corresponding authorizations for the client selected will show up in this drop-down.
8. Caregiver will auto-populate based on the user logged into the system; this is the note-writer.
9. Supervisor will auto-populate based on the assigned supervisor at the client’s record. This can be changed from the drop-down if necessary to reflect the supervisor responsible for reading and approving the note.
10. Click on Save
- Helpful Hint: Once all of the required fields have been entered, the Save button can be clicked at any time. It is recommended that you save your note periodically.
Starting a Clinical Note
Service Unit Utilization Graph
Finishing the Clinical Note
1. Select the goal from the Purpose of Contact drop-down.
- Note: depending on the note rules that have been setup per your company’s policies, you may either select the goals from the drop-down or directly key in the goals into this section. It is recommended that goals be entered on the treatment plan so that the goals are synced to the note.
- Helpful Hint: The example clinical note that is being used for this course is a standard PIE note. However, there are extensive note customization options available in the system as well.
2. Complete the Intervention and Effectiveness sections (or any other sections that may be part of a customized note template).
3. Finish the note by clicking on the Sign Note button
4. Enter the password that you use to access the system and click on the OK button
- Helpful Hint: Depending on your role and system access, you may see a “Process” button instead of a Sign Note button. In this case, you will click on 2 check-boxes (approve for billing &/or payroll) and then enter your password and click on the OK button.
5. Validation warning messages may be presented if there is anything systematically out of compliance with the note.
6. A note workflow chart (upper right of the note information screen) shows the note status.
Finishing the Clinical Note
Example Note Sign Warnings
Note Workflow Chart
A workflow chart showing the status of a note is available for reference as the note moves through the life cycle in the program (upper right of the note information screen). This helps with understanding if the note is a work in process, has been signed, approved, or billed.
