Medical Notes: How to Write a Medical Note
This section provides an overview for how to create a medical note in OnTarget Clinical.
By clicking on the Notes Desktop, users are first presented with a list of notes that have been created. This listing will only display the individual users notes, unless they are a supervisor or a Super User. For supervisors, all notes where they are listed as the supervisor are displayed. For Super Users, all notes for the clients in their assigned cost center(s) will be displayed. Use the filters on the left to drill down into the list. Double-click on the line item to go into that note to review or to edit.
To add a new note to the system, click "Add Note". Select the client.
The security settings for the user logged into the system will determine the clients displayed in the drop-down list. To verify which clients are visible in the drop down, go to the Options menu to see if the "Assigned Clients only" box is checked. If this box is checked and the client name required to write a note is not visible, the client will need to be added to the user's roster under the Employees Desktop.
If the system is being used to schedule services, then notes should be created from scheduled events. Doing so will ensure that the units flow correctly in the system and can be accurately counted. It is important to understand that the unit count will be inflated if scheduled events are not pulled into notes. To create the note from the schedule, move to the schedule drop-down field. Select the record that matches the service and date of the note to be created. Once the scheduled record is selected, confirm that all populated fields are correct, editing where necessary if applicable. Company settings determine whether or not any of the fields that pull in from the schedule can be changed.
If services are not being scheduled in the program, skip over the "schedule" field and select the "service date" by clicking on the calendar icon.
Next, select the authorized service that was provided. Each service is associated with the end date of the authorization.
After selecting the service, a "Service Unit Utilization" graph appears to the right of the screen. Hovering a mouse over any color on the graph corresponds to the unit count. "In Process" reflects all units that are tied up in the system, but not yet billed. These units could consist of time entered on the schedule or time against an approved note that has not been billed.
The template field should auto-populate to Medical Note based on the service selection. If Medical Note is not auto-populated, open the drop-down and select this option.
Enter in the "Start Time" and "End Time" or "Duration" (it is one or the other based upon the way a particular company intends to capture time per service). Be sure to include AM and PM (tip: click "A" for AM and "P" for PM).
The username logged into the system will auto-populate in the Caregiver field. There should be no reason to change this as the user logged into the system is the caregiver who is documenting the service note.
The supervisor name will also auto-populate. The supervisor name can be changed if necessary to reflect the actual supervisor responsible for reading and approving the note.
Once all of the required fields have been entered, the "Save" button can be clicked at any time. It is recommended to periodically save. While the system will provide a notification if the session is about to expire, if the system does not get a response to this message, the user will be logged out and any unsaved work will be lost.
The Medical Note template includes the following fields: Client, DOB, Date of Service, Length of Service, Service and Vital Statistics. You may then customize the template to further capture the information needed for medical documentation.
Medical Notes can be modified to include custom fields that capture identifying information, chief complaints, mental status assessments, etc through various types of fields: long text, drop-downs, short text and number & date fields.
Custom fields can be added by going to the Configure Desktop–>Customization–>Custom fields. To learn more about the process of customizing notes, refer to the section Custom Note Templates section of the help files found under the Configure Section.
The Medical Note is the only note template that includes a vital statistics tab. The vitals are one of the fields formatted to print to the medical note. The vitals can be directly added at this tab at the time of documenting the service or they may also pull in from the clients section if vitals are being maintained there. This is helpful when someone other than the note-writer (usually an assistant to the practicing medical professional) is capturing the vitals but will not be inputting the clinical documentation. Inputting the vitals at the clients section maintains that info for all staff seeing that client to review while also preventing duplicate entry onto the note.
As mentioned, the vitals can be entered in the client record (in the Clients Desktop) under the medical section. As long as the date of service on the vitals is a match to the date of the service on the note, then the vitals will be displayed on the Vital Statistics tab.
Work may be saved at any time. Even if documentation for all of the goals has not been completed, the portion that has been completed can be saved and the remaining goals can be addressed at a later time. Clicking on save closes the note. To continue working on the note, find the note in the list and click on the "Edit Note" icon.
The last step in the workflow for creating a medical note is to sign the note. The user is required to key in their password when signing the note to authenticate their signature. This is the same password that is used to login to the program.
Validation warning messages may be presented if there is anything systematically out of compliance with the note. The system will check to make sure that the following are in place:
- The caregiver’s certifications are up to date and not incomplete or expired
- The client’s consents are up to date and not incomplete or expired
- There are enough units left on the service authorization
- The time on the note does not overlap with another note
- All required fields have been entered
Below is an example of a validation warning message:
When a validation warning message is presented, users have the choice of clicking "Yes, continue processing" or "No, cancel". By clicking yes, users may proceed with signing the note. From there, the supervisor will review the note for approval. The supervisor will also receive the same warning messages and may determine at that time that the note cannot be approved for billing or for payroll. If "No, cancel" is chosen, the note will not be signed and therefore will not be eligible for the supervisor to approve. Supervisors typically determine how users should handle these warning messages.
A work flow chart showing the status of a note is available to reference as the note moves through the life cycle in the program (upper right of the note information screen). This will help you understand if it has been approved for billing, approved for payroll and whether or not it’s been billed. See example below. See the "Notes Workflow" section of the user guide for more detail.
There are several tabs within each note.
- Tasks: this tab is used for internal communication between the supervisor and the caregiver on the note. Typically this is used when the supervisor cannot approve the note and needs to provide the caregiver with the needed corrections. The caregiver can then respond to the task and alert the supervisor when the task has been completed.
- History: this tab provides an audit trail with a timestamp of all actions taken on every save.
- DMS: this tab stores the electronic record of the note. Every time a note is signed and/or unsigned a new electronic record is created. Notes can be viewed by clicking on the green arrow.
Note: the DSM5 client diagnosis information can be formatted to the medical note template. That request is done via request to support. Optionally, client medications can be included in the formatting as well. See example below.