Multi-time Grid Notes from Schedules
This section provides details on the workflow for reviewing schedules and writing notes in OnTarget.
Click on the Scheduling Desktop to begin reviewing schedules. Your scheduled events will most likely automatically display. If they do not, enter your name in the caregiver filter and press search.
The default view is the monthly view, but you can toggle to week, work week or day if needed. The schedules may be color coded-based on the way your statuses are setup. This is just a way of organizing the events; most likely by service.
For the example below, all IHSB services are blue, pcs red and respite green. You can hover your mouse over any event to see the details; such as the client, date, time and any comments entered by your supervisor.
It is important that you review your scheduled events closely; particularly for the week at hand. Any changes will need to be communicated to your supervisor immediately. The reason for this is that your notes will be written directly from these scheduled events, which is a nice short cut for writing the note along with ensuring that you are not working over the plan or authorization allotted amount of time. The most important things to review on your schedule is the dates you are working with clients and the services you are providing.
For example, if you know you are going to be providing IHSB on the 22nd, but you don’t see a scheduled event for IHSB, then you would need to contact your supervisor right away. Otherwise, you would not be able to write your note for that shift. And keeping in mind that your notes are required to be written within 24 hours, so the more you review your schedules routinely and communicate your changes to your supervisor, the better chances you’ll have to complete your documentation on time.
Changes in time are not necessarily required to be reported right away because time is the one thing you change directly on your note. In most cases you will only be able to change the time if it is less that what was scheduled. If you change the time to something over the scheduled time, then you will likely to get a message for exceeding the units. This means that you have gone over the authorized amount of units for the day or week and therefore your time for another day will need to be adjusted before you can sign your note.
You may choose to export the Calendar, which will provide you with a PDF of your schedules.
Choose the date range and then click export. From here you can either print the report or you can further export to save as PDF or Excel.
Now, we will review how to write your notes.
To write your note, you will find the scheduled shift that you are ready to document. So, you are still in Schedules and you navigate to the shift. Then click on the shift to launch the note. For this example, we will select the 9/19 IHSB link.
The client, service, template, caregiver (which is you) and supervisor will auto-populate from the scheduled info. You will then click Add Date and Time.
The service date and start/end time fields will be greyed out so the only option is to choose from the schedule drop-down. Choose the shift. You will not see any shifts past the date that you selected from the calendar. Any shifts prior to the date selected from the calendar means that you have not yet started a note for that day. This is a great reminder of notes to still be written, especially since documentation must be completed timely. In this case, I have not written the note for the 16th.
Once you have selected the shift, it is very important to review the time and ensure it is correct. If you worked something other than what was scheduled then be sure to edit the time. Your documentation should always match the exact hours worked; if it doesn’t it is considered fraudulent. As stated before, the time is the only thing that can be edited; the date nor any other element from the scheduled can be changed.
Click Save to populate the note grid.
Begin documenting the goals by marking the appropriate intervention key that was provided. The intervention keys may be different depending on the service provided. For this example, we are documenting against IHSB. You may enter in either a number between 0 and 99 or the letters x and y under any of the intervention key columns.
You will then to need to make an entry in the Assessment section. The same values are valid so you can enter in any number between 0 and 99 or either of the letters x and y.
As you complete each goal, you will see the grid lines change from yellow to white. This visual cue allows you to understand which goals have been completed and which ones have not. Yellow indicates the goal has not been addressed and white indicates that it has. The goal is considered to be complete once an entry has been made into both the intervention and assessment sections. You will not be able to sign the note until all goals are met.
You will also see as you move through each goal a shadowed line above your goal line that displays the previous entries. The previous entries are the entries made by any staff that provided the service directly prior to the service being documented. This is to help you understand how the goal was last worked so that you can make your best determination on assessing progress.
There are some keys that may require a comment. For example, if I mark in the N/A or Refused column and try to save my note, I am not allowed to save until I enter in a comment.
You may save your work at any time. Even if you have not completed all of the goals, you can save what you HAVE completed and continue addressing all of the goals at a later time. To do so, hit Save and close the note. When you want to continue working on the note, find your shift on the schedule and click it to launch the note.
When you have finished addressing all of the goals and feel you have completed your documentation of the service delivery, your last step will be to sign the note. You will be required to key in your password when signing the note to authenticate your signature. This is the same password that you use to login to the program.
You may receive warning messages 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
And that All required fields have been entered
You may have the choice to click ‘Yes, continue signing’ or ‘No, Cancel’, depending on the message. By clicking yes, you will proceed with signing your note and your supervisor will then review 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 you click ‘No, cancel’ the note will not be signed and therefore will not be eligible for the supervisor to approve. Please review with your supervisor how you should handle these warning messages. There are some messages that will not allow you to do sign at all until the issues is cleared up.
You will find several tabs within each note. The tasks tab is used for internal communication between you and your supervisor. Typically this is used when the supervisor cannot approve the note and needs to provide you with the needed corrections. You can then respond to the task and alert the supervisor when the task has been completed. The tasks will mostly be managed from the Dashboard, and you can learn more about that through the Tasks video.
The Note History tab provides an audit trail with a timestamp of all actions taken on every save.
The DMS tab stores the electronic record of the note. Every time a note is signed and/or unsigned a new electronic record is created. You can view the notes by clicking on the green arrow.
Now, we will walk through a PCS note. In this example, I worked a split shift.
Therefore, I will need to be sure to pull both pieces of time into the note. This allows me to write one note and record my split shift accordingly. If you don’t see your split shift in the drop-down, notify your supervisor.
Below is an example a Respite note.
Should you have any questions regarding reviewing your schedules or writing your notes please contact your supervisor or OnTarget Support.