PIE (Clinical) Notes: How to Add Goals to the Treatment Plan
If PIE (Clinical) notes will be implemented, there is an option of linking the goals from the treatment plan to the clinical documentation. Doing so ensures a direct match between the goal as it is written on the plan and the goal as it is written on the note. Once goals are entered on the treatment plan, they will pull over to the note, preventing the note-writer from having to key in the goals every time a note is created. It is best practice to key the goals for these reasons. Further, there is a feature that allows the goal section of the note to be locked from open keying, forcing the goals to be selected from the treatment plan.
To begin, click the Add Plan button.
Fill out the Plan Format, Plan Type and enter the Start and End Dates. Note that additional plan type and plan format options may be added by going to Options–>Contact Support to send a request to our support team.
Once a treatment plan start date, end date, format and type have been entered and saved, goals can be added to the treatment plan by clicking on the Add Goal (+) button, as shown below.
The Code field is a required field and is internal to the system and will not display on the note. Typically the code is used to number the goals.
Open Date and Close Date are used to determine whether or not the goal pulls to the note based on the service date. For example, if the open date is 6/1/2012 and the close date is 11/30/12 then the goal will not show up on a note with a service date of 12/1/12 on. It will only sync to notes with a service date between 6/1 and 11/30/12. It is important to manage these dates so that the notes have the correct goals at any given time.
**If these dates are left blank, the system will use the plan start date and end date to determine when the goals should pull over to the note.
The goal Description is required and should include the goal as it needs to appear on the note.
Click on the Save icon at the bottom right corner of the window to save the goal to the treatment plan.
Each goal will need to link to a service in order for it to display on the note. Without connecting the goal to a service, the system will not have the capability of syncing it to a note. To do so, click the Add Outcome (+) icon against the saved goal line, as shown below.
Assign the service that the goal applies to, at the minimum assigning at least 1 service. The goal can be applied up to 5 different services.
Revised Date and Target Date can be used for reference purposes only. Methodology is for reference purposes only as well. The information entered in these fields do not populate anywhere on the note. If a task analysis is required to be pulled to the note, it is suggested that any task analysis information be included in the description text box along with the outcome.
If there are multiple goals to enter, repeat the above steps by clicking on the Add Goal (+) button against the Treatment Plan line. Continue adding each goal and linking the goal to a service until all goals are entered.