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Treatment Section: How to Add Goals for Grid Notes

Treatment Section: How to Add Goals for Grid Notes

Treatment Plan information must be entered if billing or notes will be implemented.

For billing purposes, the minimum treatment plan info required is the plan start date, end date, format and type. This information is then tied to the service authorization in OnTarget Back Office. After hitting Add Plan, these required fields are presented. Once saved, this creates the treatment plan link that can be associated with the authorization.

 

 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.

 

If Grid notes will be implemented, there is an option of linking the goals and outcomes 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.

 

Once a treatment plan start date, end date, format and type have been entered and saved (per the steps above), 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. For Grid Notes, this is typically considered the 'Long Term Goal'. This description can be visible on the note, but it is not the actual goal that the caregiver/note-writer is addressing. It is the overall goal that individual outcomes or task analysis' belong to. 

 

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 an outcome and  service in order for it to display on the grid note. Without connecting the goal to an outcome and service, the note-writer will not be able to write a note.   To do so, click  the Add Outcome (+) icon against the saved goal line, as shown below.

 

 

 

The Code for an outcome can be numbered or labeled if it needs to be displayed on the note.  When displayed on a note, the outcome code is tied to the goal code.  For example, if the goal code was chosen as "1" and the outcome code was chosen as "A", then the goal on the note would display as goal "1A".

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.  

Enter in the outcome in the description field. This is required for grid notes and is the actual goal the worker will be addressing on the note.

 

 

Revised Date and Target Date can be used for reference purposes only.

Date Completed is another option to use to control when the outcome should pull to the note.  It is recommended that this field be used when you have multiple outcomes associated with the goal and an individual outcome has been met while other outcomes are still valid. Rather than having to end date the whole goal, which would then prevent all of the outcomes tied to that goal from pulling to the note, the user can end date the individual outcome by using this field.

 

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.

 

If there is more than one outcome associated with a goal, then additional outcomes can be added by clicking the + button (Add Outcome).  Repeat the steps for entering in the additional outcomes.  If multiple goals are required, click on the + button (Add Goal).  Repeat the steps for entering in the additional goals.