Inpatient Progress Notes (Diagnosis Entry)

Displaying Final plans

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.
• A diagnosis must be assigned to the client in the Diagnosis form (Avatar PM).
• The service must be added to the Workflow Service Setup section in the CWS Set System Defaults form.
• A service must be scheduled for the client.
• 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.
• In the Select T.P. Version field, a treatment plan must have been created in a treatment plan form.
• Progress note draft/final functionality is enabled through the Include Draft/Final Prompt registry setting.
• Functionality can be added to these forms through Site Specific Section Modeling.

Note Details  

1. In the Select Client screen, search for and select the client by name or ID.
2. If the client has multiple episodes, select the client's episode, click OK.
3. 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 still 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.
4. In the Note Type field, select the progress note type.
5. In the Notes Field, enter the progress note text.

Link to Treatment Plan & Staff  

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.
3. 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.

For Diagnosis Forms  

1. In the Active Diagnosis field, select the active diagnosis.
2. In the 'Diagnosis' fields, enter the diagnosis code, click Process Search. Click OK.

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 Section

• Progress Notes

► Registry Settings

• Attach Selected Appointment To Notes On Draft
• Clear Fields When Selecting an Existing Appointment/Service
• Enable Evidence Based Practice Fields  (Avatar PM)
• Enable Incident-To Practitioner (Avatar PM)
• Enable Practitioner
• Fields to Include in Client Charge Input (Avatar PM)
• Filter Active Medical Diagnosis (Avatar PM)
• Generate Service Charge After Co-sign
• Incident-To Practitioner Default (Avatar PM)
• Include Client Information Report
• Include Co-Practitioner
• Include Co-Practitioner 2
• Include Discipline (Avatar PM)
• Include Draft/Final Prompt
• Include Location
• Include Number Of Clients In Group
• Include Service Fields Within Predisplay
• Include Start - End Times
• Number Of Allowed Note Diagnoses
• Send Draft To-Do to Submitting User

► See Also

• Record Locking