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Create Both Progress Notes and Services

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Create a new client service, and attach a progress note to the service.

Prerequisites:

  • The client must be enrolled in a treatment program.
  • The service rendered in the appointment must be added to the Workflow Service section in the CWS System Defaults form.
  • The user must be the service provider who rendered the service, or associated with the service provider for the client service (User Definition form, User Caseload section).
  • If a treatment plan is selected in the Select T.P. Version field, a treatment plan must have been created in a treatment plan form.
  • If the 'Include Discipline ' registry setting is enabled, the practitioner must be associated with the same discipline as the service code.

The following fields apply to clients with outpatient episodes.

  1. Select a progress notes form from the myAvatar CWS Progress Notes menu.
  2. In the Select Client screen, enter the client ID in the Client Name/ID field, then choose Select Client Name/ID Search.
  3. Select Ok.
  4. If the client has multiple episodes, select the client's episode and select Ok.
  5. In the Progress Note For field, select New Service.
  6. In the Date Of Service field, enter the service date.
  7. In the Service Charge Code field, enter the service code, and select Process Search.
  8. Click Ok.
  9. In the Service Program field, select the program.
    Note: If a program does not display, check the following 'Enable Admission vs. Service Program Functionality ' registry setting.
  10. In the Service Duration field, enter the duration.
  11. In the Location field, select the service location.
  12. In the Note Type field, select the progress note type.
  13. In the Notes field enter associated progress note text.
  14. If appropriate, in the Select T.P. Version field, select the treatment plan the progress note is associated with.
    Click Select T.P. Item Note Addresses. Choose the treatment plan item, click Return.
  15. The Note Addresses Which Treatment Plan Problem field displays the treatment plan item structure.
    Note: The Use Date Of Service registry setting can affect this field.
  16. Select the user who will co-sign the progress note.
    Note: The User List Management and Notification Users forms define the available users.
    Depending on the note type definition, this field may be required, or may be disabled. 

    For Diagnosis forms:
  17. In the Active Medical Diagnosis field, select the active medical diagnosis.
  18. In the Diagnosis fields, enter the diagnosis code
  19. and select Process Search.
  20. Click Ok.
  21. Select the user who will co-sign the progress note.
    Note: Depending on the note type definition, this field may be required, or may be disabled.​
  22. If interactive complexity or psychotherapy add on functionality has been associated with the service code:
    In the Additional Service Information field:
    • Select Interactive Complexity for interactive complexity services.
    • Select Psychotherapy Add-On for add-on services.
  23. In the Psychotherapy Add-On Duration field, enter the service duration.
  24. In the Add-On Notes field, enter any notes associated with the add-on service.
  25. In the Clinical Instructions field, enter associated instructions.
  26. In the Recommended Decision Aids field, enter recommended aids.
  27. In the Reason for Visit field, select the visit reason.
  28. Select Submit.