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Inpatient Progress Notes

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Record clinical events for a client enrolled in an inpatient treatment program. This form has 2 sections (and 2 sub-sections:

It can also contain Interactive Complexity or Psychotherapy Add-Ons that display (and require) other fields when specific services are selected.

Inpatient Progress Notes can be used in conjunction with services added to the Workflow Service section in the CWS System Defaults form.
In these cases, the staff’s schedule must be verified in myAvatar PM (Verify Staff Member Appointments form), and posted (Post Staff Member Schedule form). Or use the Post Staff Activity Log form which verifies and posts the appointment.

Progress note draft/final functionality is enabled through the Include Draft/Final Prompt registry setting. Functionality can be added to modeled sections on this form through Site Specific Section Modeling.

Treatment plans marked as Final will display when:

  • The Display Only Treatment Plans Finalized by All Approvers field is set to Yes on the Set System Defaults form
    and 
  • Document Routing is disabled

Prerequisites

  • The client must be enrolled in an inpatient or partial hospitalization treatment program.

Create Inpatient Progress Note

  1. Go to: Avatar CWS > Progress Notes > Inpatient Progress Notes
  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, click OK.
  4. In the Progress Note For field:
    • Select Existing Service to attach a progress note to an existing client service.
      1. In the Note Addresses Which Existing Service/Appointment field, select the service. Posted services without an associated progress note display.
      2. 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.
      1. In the Note Addresses Which Existing Service/Appointment field, select the appointment. Posted appointments without an associated progress note display.
      2. 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.
      1. In the Date Of Service field, enter the service date.
      2. In the Service Charge Code field, search for and select the service code.
      3. 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.
      4. In the Service Duration field, enter the duration.
      5. In the Location field, select the service location.
  5. In the Note Type field, select the progress note type.
  6. In the Notes Field, enter the progress note text.
  7. 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.
  8. 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.

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.
    When finished, click Submit.
► Additional Sections
► Registry Settings
► See Also