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Grid Notes: An Overview

Grid Notes: An Overview

The grid note is one of several note formats available in the program.  This style of note is best used for services that require goals to be documented against a set of interventions and assessments in a grid-like format.  One of the main benefits to using this style of note is that the data can be graphed to demonstrate progress toward each goal over a specific period of time.

 

Each note is created by associating it with a client and an authorized service.  When selecting the authorized service, a graph will display to show the available units.  The service selection will also determine the set of goals that will display.  Goals pull into the note from the treatment plan and only the valid goals for the date of service entered will be displayed.  A set of keys is listed along the top that are used to address how the goals were worked for that day.

 

Typically, the keys are used to show the interventions that were provided against each goal and whether or not those interventions assisted the client in reaching the goal.

 

The system allows for full control over how intervention and assessment keys are set up.  Keys may be set up uniquely for each service provided.  This allows note keys to be tailored to each individual service’s documentation requirements.

 

Users have flexibility in setting up various styles of grid notes to accurately document against different service codes.  The example below demonstrates this level of flexibility by showing one note form with both Intervention and Assessment Keys, and another where the Intervention keys have been omitted.

 

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Terminology other than intervention or assessment can be used when creating note keys.  For example, it may be important to document where the service was provided, whether in the home or in the community. In that case, you could create keys for Home and Community under the heading of "Location of Service".

 

Additional fields can be added to the standard format as well.  As an example, a text field may be added to allow for generic comments.  The note customization tool is what allows additional fields to be added to what is available on the standard form.

 

A benefit of using grid notes is that data can be graphed to report on progress toward each goal.  Once notes have been implemented, progress can be measured through the "Assessment Progress by ISP Goals" and "Intervention Use by ISP goals" dashlets.   

 

Below is an example of a graph generated under the Assessment Progress by ISP Goals dashlet (under the Dashboard Desktop).  This view is set for a specific client, service, and time period.  The assessment keys are color coded on the right.  By hovering the mouse over each bar, users can see the total percentage of time each key was used for each goal.

 

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The intervention graph works in a similar way, but will color code the intervention keys and display the percentage of time each prompting level was used against each goal.  This graph can be accessed under the Intervention Use by ISP goals dashlet.  This view is also set for a specific client, service, and time period.

 

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