PROGRESS NOTES
In this user guide we will cover, entering a progress report, editing a progress report, generating a PDF progress report or a summary list of reports as well as how to easily search for specific progress notes by key word or date.
CREATING A NEW PROGRESS NOTE
Log into the provider application and access the consumer’s chart.
Click on “Service Delivery Logs” (green circle)
Click on the “Progress Notes” tab (blue circle) and then click on “+Add Progress Note” (red circle).
When the pop-up window appears, enter all relevant information into the designated boxes
*Disclaimer* When entering the “Place of Service” if you choose ‘Home’ or ‘Office’ the system will automatically fill out any previously entered addresses for the specific consumer’s home or the company’s main office location in the final report. There is no need to enter that information.
However if any other type of “Place of Service” is chosen you must fill out an address in the “Service Address” field (red arrow).
If you don’t want an address to show on the report simply put any text in the “Service Address” field.
Files corroborating information in the progress notes can be attached by uploading them from stored locations on your computer by clicking on the “select” button (green arrow). Please wait at least 10-15 seconds to allow full uploading or wait until the upload icon indicates that the process is complete. Failure to carry out the preceding steps may lead to a failure of the upload process and a subsequent inability to retrieve the documents later. Once all the data required is uploaded click “Save” (red arrow) to save and exit.
Only the originator of a progress note can edit it after creation and only their signature and initials appear on reports. To include a signature on the document click the radio button (orange underline). To save the document click the “Save” button (purple circle).
You will be returned to the consumer’s main information page. To view the newly created progress note or any previously entered click on the “Type of Notes” bar (red arrow).
From the drop down menu options choose a progress note type (blue circle).
Once this is done the list of the specific type of progress notes chosen will appear (purple circle) and a report generated by clicking the “Report” button to the far right of the specific progress note you want.
Progress note reports can also be retrieved from the home page or a consumer’s main information page by clicking the “Reports” tab (red circle) and then clicking on “Progress Notes” (green circle). A side bar will appear on the right. To create individual progress note reports click on ‘Progress Note’ (blue circle or to create a summary sheet of a list of progress notes, click on ‘Progress Note/log Summary’ (yellow circle).
If a progress note is needed, then click on the appropriate button. When the pop up window appears fill out the required fields as indicated and then click “submit”. A report for the specific consumer and progress note type will be generated.
Example:
EDITING A PROGRESS NOTE
Log into the provider application and access the consumer’s chart. Click on “Service Delivery Logs” (green circle). Click on the “Progress Notes” tab (blue circle). Click on “Types of Notes” (red arrow)
From the drop down menu options choose a progress note type (blue circle).
Once this is done the list of the specific type of progress notes chosen will appear (orange circle). Click the “Edit” button (green arrow).
Scroll down in the pop-up window and click the “Edit” button (purple circle). Make any changes to the consumer’s note. When finished scroll down again and click the button that now says “Save” (orange circle).
Generate a summary list of progress notes grouped by the originating staff’s name
Click the “Report” tab on the main menu bar (red circle). Then click on “Progress Notes” (green circle). Click on “Progress Note/Logs Summary” (blue circle).
When the dialog box opens chose the appropriate Branch/Contract you wish to search, the staff name (if staff has been terminated check off the “Terminated Staff” box), the log type, and its current status (i.e. approved, billed, etc.) as well as date search parameters.
When a staff name(s) is chosen the system will automatically generate a report of all logs created by that staff over all branches/contracts. There is no need to search each contract. Once complete click “Submit”.
A progress note summary is then generated.
Example:
If some nursing or psychology/behavioral progress notes do not appear under a search for approved progress notes your company may have chosen a Director of Nursing (DON) and/or A Director of Psychology (DOP). For logs under their purview to be recognized as approved, they (DON or DOP) must sign off. Remember even if you later decide not to route logs through this position any logs created when DON/DOP enforcement was in effect MUST be approved by such an individual.
Searching for a Progress Note By Key Word or Date
To search for a specific progress note, simply ensure you are in the client’s chart and have the list of progress notes you want to search showing (purple box). You can either search all progress notes or define a specific type of progress note you wish to search form the ‘Type of Note’ drop-down (green arrow), eg ‘Daily Contact Notes’, Psychological Evaluations’, ‘Progress Notes’, ‘Monthly Home Visits’ etc. Once the list is showing, go to the search field in the upper-right hand corner of your screen (Blue circle) and put in a key word that was contained in the ‘Descriptor’ field of the progress note. You can also search by the year or month numeral, eg 2020 or 04 for April. (DO NOT IN A DATE FORMAT, like 02/04/2018.) Hit the search button (red arrow). The system will pull up all notes in the folder chosen with the searched item. In the example below, the search term was ‘wound’ but could have been a year such a 2020.
