Residential: Shift Notes

Residential: Shift Notes

In this course we will review how to launch notes directly from shifts on the scheduler. These are shifts

  1. Click on Scheduling.
  2. Filter to your Site. You may use  any of the  filters as needed depending on how its easiest for you to search for your schedules.
  3. Click on the link for the most current date of your shift in the calendar view.
  4. Click on the Add/Edit Note link beside the client for whom you are writing a note.
  5. Notice that each caregiver that is scheduled for the corresponding shift will display. Both caregivers may author the note and both are required to sign the note. If only one of the caregivers will author and sign, the others must be deleted – which can be done by a supervisor or notes superuser. When a caregiver has signed the note, the date signed field will update with a digital timestamp.
  6. Click Save to see the client’s goals.
  7. Complete Intervention and Assessment sections.
  8. The goals will change from yellow to white as goals are addressed.
  9. As with all grid notes, each goal requires at least one intervention and one assessment.
  10. Some keys may require a comment for additional detail.
  11. There may be additional fields to complete and will display underneath the goals if so.
  12. To add general comments or to provide a general summary of the shift, click the Add Shift Comment button. Each caregiver can do so and the system will provide the audit of which caregiver is entering the note.
  13. Sign the note by entering the password. 
  14. For group notes where multiple signatures are added to a single note, the final signature must be applied after the end time of the shift has passed.  Other caregivers are allowed to sign prior to the shift end.

We should also review the notes dashlet on the Dashboard,  as that can be a very useful tool in knowing the signed status of each note, especially useful if you are not authoring the note but need to sign off on it. The Group Note Signed column is specific to shift notes. if this is checked it is an indicator that you have signed off on it. When it is not checked, and you see your name listed with other caregivers in the caregiver column, that is an indicator that you need to sign off on it. you can launch the note directly from here in order to co-sign it. If you see notes in this dashlet, it is highly recommend to review them and sign since Once signed, they will be removed from the list.  this is designed to simply help you get your notes to a signed state and off of your to-do list. You can always retrieve any note by going directly to the Notes desktop.

Notes can also be launched from a mobile phone as well.