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Multi-Time Notes: How to Setup and Write a Multi-Day or Time Note

Multi-Time Notes: How to Setup and Write a Multi-Day or Time Note

This section provides an overview for how to create a multi-day note in OnTarget Clinical.

 

The Multi-Day note template best serves clinical documentation guidelines that allow for multiple days of services to be entered on a single note.  If the system is being used to bill for these services, the billing is also supported so that the each date of service on the note is billed accordingly.

 

To set up a Multi-Day Note template, go to ConfigureàList ConfigurationàServicesàNote Templates.  Click Add Note Template.

 

Give the template a description.  This will be the common name for this note format, meaning this is how the note will be referenced in the drop-down selection list for note templates.  Select a Note Type.  At this time, multi-day notes are only configurable for Clinical Notes (the equivalent of a PIE note) and Grid Notes.  It is not an option to set this up for Medical Notes.  PIE notes can be customized by either re-labeling the fields or by adding custom fields.  Check the Multi-Day Note checkbox and Save.

 

 

A note template may be set as the default template for a corresponding service.  This is recommended to ensure that the note-writers are completing their documentation against the correct note type.  Without a default note template set per service, the note-writer is forced to choose the template to write their note upon; leaving room for error.  To set the default, go to ConfigureàList ConfigurationàServicesàState Services.

 

 

Find the service in the list and then set the default template accordingly. 

 

 

Once the Multi-Day Note template is set up, go to the Notes Desktop and click "Add Note".  Select the client.

 

 

The services that populate for the client are authorized services based on the service date entered.  If the default template was set, then the form will default to the multi-day note template.  If the default was not set, then the note-writer would need to select the template in order to get to the MDN format.

 

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.  It is important to understand how an individual agency intends to use the schedule with the 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.

 

Next, select the authorized service that was provided.  Each service is associated with the end date of an authorization.  Selecting the correct service provided is critical so that the corresponding goals for that service are displayed.

 

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.

 

 

Click on the add a date and time button and add a service date and start and end times.  If services are not being scheduled in the program, skip over the schedule field. 

Repeat this process in order to enter multiple date and time entries.  

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.