Create Progress Notes for Services

Attach a progress note to a client service.

Prerequisites:

• The client must be enrolled in a treatment program.
• The service must be added to the Workflow Service Setup section in the CWS Set System Defaults form.
• The user must be the service provider who rendered the service, or is associated with the service provider for the client service (User Definition form, User Caseload section).
• If a treatment plan is selected (Select T.P. Version field), a treatment plan must have been created in a treatment plan form.

1. ---

   Select a progress notes form from the myAvatar CWS Progress Notes menu.
2. In the Select Client screen, search for and select the client by name or ID.
3. If the client has multiple episodes, select the client's episode, select OK.
4. In the Progress Note For field, select Existing Service.
5. In the Note Addresses Which Existing Service/Appointment field, select the service.
   Note: Service information fields will populate with the associated data for that service.
   Result: Posted services without an associated progress note display.
6. In the Note Type field, select the progress note type.
7. In the Note Text field enter the progress note text.
8. Optional: If appropriate, in the Select T.P. Version field, select the treatment plan the progress note is associated with.
   • Choose Select T.P. Item Note Addresses.
   • Choose the treatment plan item, select Return.
9. The Note Addresses Which Treatment Plan Problem field displays the treatment plan item structure.
   Note: You can clear this field by clicking Clear 'Note Addresses Which Treatment Plan Problem' Text. The Use Date Of Service registry setting can affect this field.
10. 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.
    
    For Diagnosis forms:
11. In the Active Medical Diagnosis field, select the active medical diagnosis.
12. In the 'Diagnosis' fields, enter the diagnosis code, select Process Search. Select OK.
13. Select the user who will co-sign the progress note.
    Depending on the note type definition, this field may be required, or may be disabled.
14. Optional: 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.

15. In the Psychotherapy Add-On Duration field, enter the service duration.
16. In the Add-On Notes field, enter any notes associated with the add-on service.
    Note: The following fields apply to clients with outpatient episodes.
17. In the Clinical Instructions field, enter associated instructions.
18. In the Recommended Decision Aids field, enter recommended aids.
19. In the Reason for Visit field, select the visit reason.
20. If billing according to CQIs, select the codes in the Clinical Quality Indicators field. This field is populated with codes that have been set up in the Clinical Quality Code Configuration form.
    • In the Is This A Transition Of Care? field, select whether or not one of the selected code(s) represents a transition in care. This field is used for Meaningful Use reporting to designate when a client is considered a transition of care encounter.
21. Select Submit.
    Note: If a To-Do item is not sent, or a service does not display in the Note Addresses Which Existing Service/Appointment field, check the following registry settings:

• Allow 'Progress Note' Forms To Default All Active To-Dos
• Days After Service Date to Allow a Progress Note
• Days Prior To Service Date To Send To-Do
• Suppress To-Do Items Prior To Date