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Create client progress notes

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Create client progress notes.

Prerequisites:

  • The client must be enrolled in a treatment program.
  • In the Select T.P. Version field, a treatment plan must have been created in a treatment plan form.
Individual Note Details 
  1. In the Select Client field, search for and select the client by name or ID.
  2. If the client has multiple episodes, select the specific episode from the Select Episode field.
  3. In the Progress Note For field:
    • Select Existing Service to attach a progress note to an existing client service.
      • The service must be added to the Workflow Service Setup section of the CWS Set 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).
      • In the Note Addresses Which Existing Service/Appointment field, select the service. Posted services without an associated progress note display.
      • Service information fields will populate with the associated data for that service. 
    • Select Existing Appointment to attach a progress note to an appointment before posting the appointment. Once the appointment is posted it is converted into a service. Progress notes for posted appointments cannot be edited.
      • A service must be scheduled for the client.
      • The service must be added to the Workflow Service Setup section of the CWS Set System Defaults form. This will create the Scheduling Calendar Icons for Note Required, Note in Draft, and Finalized Note.
      • 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).
      • In the Note Addresses Which Existing Service/Appointment field, select the appointment. Posted appointments without an associated progress note display.
      • Service information fields will populate with the associated data for that appointment and its associated service.
    • Select Independent Note to create a progress note that is independent of a client service.
    • Select New Service to create a new client service and attach a progress note to it.
      • The service must be added to the Workflow Service Setup section of the CWS Set System Defaults form. This will create the Scheduling Calendar Icons for Note Required, Note in Draft, and Finalized Note.
      • In the Date Of Service field, enter the service date.
      • In the Service Charge Code field, search for and select the service code.
      • In the Service Program field, select the program.
      • When the registry setting Restrict Practitioner Search By Program is set to 'Y' and a practitioner is selected, the Program field will remove any programs that are not associated to the practitioner. This will include any program that may have been associated to an existing service or appointment but is not currently associated to the practitioner.
        • If a program does not display, check the following Enable Admission vs. Service Program Functionality registry setting.
        • In the Service Start Time and Service End Time fields, enter the start and end times in HH:MM AM/PM. When both times are entered the Service Duration field will be calculated automatically. 
        • In the Service Duration field, enter the duration, if applicable.
        • In the Location field, select the service location.
        • In the Practitioner field, search for and select the practitioner name.
  4. In the Note Type field, select the progress note type.
  5. Select the User To Send Co-Sign To Do Item To.
    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.
  6. In the Notes Field, enter the progress note text.
  7. In the Reason for Visit field, select the reason for the client's visit. 
Select Treatment Plan for Note
  1. 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.
  2. The Note Addresses Which Treatment Plan Problem field displays the treatment plan item structure. 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.
Interactive Complexity or Psychotherapy Add-Ons 

Used if interactive complexity or psychotherapy add-on functionality has been associated with the service code.

  1. In the Additional Service Information field:
    • If interactive complexity is present during the service, select Interactive Complexity to render interactive complexity services associated to the Service Code.
      Interactive Complexity is only available for service codes that are defined as Evaluation Management, Psychotherapy, or Group Therapy from the service code setup.
    • If psychotherapy is present during the service, select Psychotherapy Add-On to render the Add-On Service Code associated to the Service Code.
      Psychotherapy Add-On is only available for service codes that are defined as Evaluation Management from the service code setup.
  2. In the Psychotherapy Add-On Duration field, enter the service duration.
  3. In the Add-On Notes field, enter any notes associated with the add-on service.
Outpatient Episodes 

The following fields apply to clients with outpatient episodes.

  1. In the Clinical Instructions field, enter associated instructions.
  2. In the Recommended Decision Aids field, enter recommended aids.
  3. In the Reason for Visit field, select the visit reason.
    This field populates with problems entered for the client in the Problem List form.
Clinical Quality Indicators 

Used if billing according to CQI's for Meaningful Use.

  1. In the Clinical Quality Indicators field, select the codes. This field is populated with codes that have been set up in the Clinical Quality Code Configuration form.
    If the registry settings Activate Program/Service Code Filter and Include Clinical Quality Indicators for Billing are set to 'Y', the Clinical Quality Indicators are filtered by their associated service codes as the form is filled out.
  2. 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.
  3. When finished, click Submit Note.
► Registry Settings

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:

► See Also
► Test Scripts

For implementing new systems or new functionality, download the following standard test script for this feature. Please contact your Netsmart representative for more information about Test scripts.