If grid notes are being implemented, note keys will need to be set up. These keys are the method in which goals are addressed. Typically, the keys are used to show the intervention that was provided against each goal and then an assessment is made to indicate whether or not those interventions assisted the client in reaching the goal. There is full control over how key types are set up.
Note Keys: Overview:
Below is an example of some intervention keys. 'I' is marked when the goal has been completed independently, 'VP' is marked to show the number of verbal prompts provided, 'G' is marked when the goal included a gesture prompt, and so on.
Here is an example of some assessment keys. Y is used to indicate that yes, the goal was met; N/A for goal not applicable on this service date, R for the client Refused the goal and N that the goal was not met. When keys are set up, there is the option to require a comment when one of the keys is used.
Keys may be set up uniquely for each service that is provided. This allows the keys to be tailored to each of the service’s documentation requirements.
Once grid notes have been implemented, graphs will be available and aggregate the data from the interventions and assessments keys to show progress against goals. The first graph in the example below shows the percentage of time the intervention keys were used to meet the goal. By hovering the mouse over each line, each goal and the interventions used for the specified period of time are visible.
In the example below, the assessment keys indicated the percentage of time the goal was met. Hovering the mouse over the lines will display the goal and its associated assessments. By clicking on the export button from the graphs, a report can be generated. It is important to understand that the way in which the keys are configured is critical to how the goals are being worked.
Configuring Note Keys:
To start configuring note keys, from the Configure Desktop, click on List Configuration—>Services—>Note Keys.
Click on "Add Note Key" and select whether the key is an intervention or assessment key. Key types other than intervention and assessment labels can be requested by going to Options—>Contact Support.
It is important to note that any new key type will not be able to be graphed to measure progress so it is recommended to use the intervention and assessment key types.
Enter in the key abbreviation under code. This is how the key will be displayed for the staff when their note is created. Next, enter in the key description. This will show up on the note report in the form of a legend.
If a comment is required to be entered on the note when a particular key is used, then check the "Require Comment" box. The staff will then not be able to save their note unless a comment is entered into the comment field.
Click Update to save the record.
If the key needs to be edited, click the Edit icon. To delete it, click delete.
Repeat these steps to continue building the keys. The keys will display on the note in the order they are presented in the list view. To change the order, drag and drop the keys until they are in the desired order.
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