Progress notes data entry includes entering, updating, and deleting progress notes. Additionally, as part of the process of entering progress notes the contacts log is automatically updated with a record for that contact.
- From the left-side navigation menu, select Charts > Services-Individual > Progress Notes.
The Progress Notes Data Entry page will display.
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Select the Client from the drop-down menu. Note: If the client is a former (discharged) client, click "Roster Archives".
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If you have the "Surrogate Data Entry - Progress Notes" exception override permission, select the Worker for whom the progress note data entry is being completed. Otherwise, skip this step.
- Continue.
The Progress Notes Editing Index page will display.
This page includes all the existing progress notes written for the selected client that fall within the editing window date range shown at the top of the page. Progress notes with corresponding contacts log records are indicated by an asterisk (*).
Note: By default, the Progress Note Index is limited to displaying only the notes you wrote. There is an option that expands the index to include all notes written for the client (from all note writers). If you would like this expanded view, please contact the Help Desk.
- Select the note you would like to update or select New Note.
Note: a solid bullet next to a note indicates one or more of the following:
- That you did not write the note and do not have the authority to access it in data entry mode. Only the user who entered the note, or someone with the "Surrogate Data Entry - Progress Notes" permission can edit it.
- That the note falls outside of the editing window. If you do not already have the "Backdated Progress Notes Data Entry" permission, having that assigned to you may enable you to make necessary edits.
- That the note has been locked and cannot be opened for updating. If necessary, locked notes can be unlocked by users with the "Unlock Progress Notes" permission, at which point they can be selected for editing.
Note: A lock and key icon next to a note indicates that it has been electronically signed, preventing edits.
Note for BillingBuilder Clients: Progress notes used to generate invoices for procedures associated with configured Daily/Per Diem and Fee for Service billing types will be locked once invoices have been posted to A/R. The Progress Note Index page displays a dollar sign ($) next to notes that have been used for billing purposes. Edits can be made to all of the progress notes used to generate the invoices in a batch if the batch of invoices is unposted from A/R using the UNPOST BATCH button on the Create Insurance Claims page of the BillingBuilder. Users with the required permissions can also choose to unlock specific progress notes on the note editing index and this action will be recorded in the Audit Trail noting whether the billed status was removed.
- Continue.
The Progress Notes Data Entry Settings page is displayed.
- Enter or make changes to the information on this page.
- If "Service Plan Linked" is selected in the Progress note Type Selection, click Continue and the Service Plan Note Linkage page will display. Click the radio button next to the goal/objective associated with this progress note.
- For other note types, click Continue and the Progress Note Data Entry page will display.
- If necessary, select the Service Type from the drop-down menu.
- Using the Crisis? drop-down menu, indicate if the note is "Crisis" or "Routine".
- Type the note in the text box.
- If necessary, click the Lock Progress Note checkbox. When this is selected, no note overwriting, edits, or deletions are allowed after the note is saved.
- Save Note.
- Click Note Index to return to the Individual Progress Notes Editing Index page.
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