Question:

I cannot delete my note.  What do I do?

Answer: 

If you have already signed your note, the system will not allow you to delete the note.  This is in order to remain in compliance with guidelines for electronic documentation.  If you have not already signed the note, you can delete the note by going to the Notes Desktop and selecting the red trashcan next to the client name for the note to be deleted.  If the note can be deleted, the note will disappear once you have answered "yes" to the delete confirmation pop-up .  If this note cannot be deleted, you will receive an error message.

Question: 

When I click on the Edit Note icon (pencil tool), I can get to my note, but I can't edit it.  What do I do?

Answer:

First, verify that the note is listed as "Work In Process" on the note workflow chart (right hand side of the note information screen).  Only notes that are listed as "Work In Process" can be edited.  If the note is listed as "Signed", then you will need to un-sign the note to make any edits.  If the note is listed as "Approved", then you will need to contact your supervisor to let them know that they need to un-approve the note so that you can un-sign and edit the note.  If the note is listed as "Billed", then the note has made it through the entire billing cycle.  Only the content of the note can be edited at this point (service/times/etc. are locked).  In order to edit the content of the note, you would need to follow the steps outlined above for editing a note that is "Approved". 

Question:

Why are the goals/outcomes that I created for a client not being pulled into a note? 

Answer:

In order for goals/outcomes to pull to a note, outcomes must be linked to a service.  To verify that the outcomes are linked to a service, go to the treatment plan section of the client and select the outcomes associated with the treatment plan.  Ensure that each outcome has an associated service.  If not, add a service and click on Save to save the link to the client record. 

Question:

I have completed my note, but have contacted my supervisor to let them know that one of the goals/outcomes is not correct that has pulled to the note.  What do I do?

Answer:

Once a note has been saved (Work In Process), the goals that pulled to the note at the time of the save are typically locked to the note.  Even if a supervisor makes changes to the goals/outcomes after a note has been saved, the goal/outcome change will not automatically populate to an already saved note.  At this point, it would be best practice to delete the note (as long as it has not been signed), and start the note-writing process over again.  This will ensure that any changes that have occurred to the treatment plan goals/outcomes will get pulled to the new note for documentation purposes.      

Question:

I need a printed copy of my note(s).  How do I do that?

Answer:

Using the filters on the left side of the Search Clinical Notes window (Notes Desktop), drill down to the note(s) that you would like to print.  Once the note(s) are in view, simply click on the Print Notes button at the bottom of the window.  This will generate a .pdf document for printing purposes.

Question:

I am a supervisor.  How do I review and approve multiple grid notes at once? 

Answer:

Using the filters on the left side of the Search Clinical Notes window (Notes Desktop), drill down to the grid notes that you need to review and approve.  Select each note in the notes view by using a check mark, and click on the "Approve Grid Notes" button.  Once you have done this, a window will appear showing dates for all of the notes selected and interventions/assessments used for each goal addressed per date.  If you have reviewed all of the information and are satisfied with the caregiver's data, simply click on the "Approve" button, enter your system login password, and click on "OK".

Question:

I am a supervisor.  I need to unapprove a note so that the staff can make corrections to it.  However, the note already has billing associated with it.  What do I do?

Answer:

If you only need to make changes to the content of the note, then you simply need to unapprove the note and notify the staff so that they can unsign and make the necessary corrections.  If the changes required are to the time, date, or service, you will first need to contact your billing specialist so that they can void the billing associated with the note and delete the time record from actual time.  Once this has been done, you can proceed with unapproving/unsigning the note. 

Question:

I need to create a single note with multiple time entries.  How do I do that?

Answer:

In order to create a single note with multiple time entries, you must create  a note using a template that has the "Multi-Day" function enabled.  Note templates are set up by going to Configure–>Services–>Note Templates.  The "Multi-Day" field should be set to "Yes" for the template in order to enable this functionality.  This template should then be linked as the default for the service being documented by going to Configure–>Services–>State Services.

Question:

I am a supervisor and I need to ensure that a note is not processed with billing, but the note has already been signed and cannot be deleted from the system.  How do I get the note cleared from my dashboard and ensure that the note is not processed with billing?   

Answer: 

First, you will need to instruct the note-writer to un-sign the note so that it is editable.  Next, the note-writer will either "zero out" the note by changing the start and end times to the same time (change to "0" for duration only), or they will change the service to a non-billable code for the note.  Finally, the note-writer should sign the note and then you should approve the note.  Once a note that has been "zeroed out" is signed/approved, it does not get billed by the system.