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Progress Notes (article)

Summary:

Notes can be created and managed via the My Sal Calendar or other client areas in the PIMSY system. The following instructions apply to any area where you are doing Progress Notes. The Progress notes are useful for documenting outpatient therapy, enhanced service, such as case management, nonbillables, etc.

Also refer to this article on DIAGNOSIS CODES ON RELEASE NOTES.

Notes will automatically save every minute or so as users are typing them. The automatic saving starts after the initial Save and continues as the clinician is working until the user checks the Release box.

There are 3 classifications of notes in PIMSY:

  • New Therapy / Progress Note
  • New Assessment / Medical Follow-up Note
  • New Group Note

Buttons:

Take Payments – take a payment from the client directly from the Note.

Answers -  quickly copy text answers on any Q&A forms in the client's chart into a particular note. (see instructions below)

Open Last Note – open the last note on this client.

Note Report – prints the note for release.

Leaf Icon – In PIMSY, there are green leaf and red-brown leaf icons. Green leaf and green tree icons are related to money items, invoices etc.

Brown leaf icons are always report related, usually printable reports. If the button has a brown leaf and text it will pull up a printable report for whatever subject you are on in the system.  If the button has a brown leaf only, then you will have options as to which report you want to generate.  There may be multiple standard options here or there could be multiple custom reports just for the specific client as well.

Docs – this button allows the clinician to attach documents to a specific note rather than the overall chart.

View Client – view the client’s chart.

Font Size – increase or decrease the font size in the free-text area.

ABC – spell check for the free-text area.

Fields:

Service Date – the date this service was provided.

Duration – the duration of the session.

Location Code – where the service was performed.

Billing Code – the service that was performed or the code that fits the information being documented.

Face to Face – check this if the visit was face-to-face with the client.

Collateral Note – indicates that the session took place with collateral contacts rather than the client.

Released for Review – releases the note for review when dual-signoff has been indicated in the User’s file.

Released – the note is released, locked, and invoiced.

Note Type – see the dropdown for note types.

Division – if applicable.

Allow Unconditional Release – an administrative field that bypasses system note rules in order to allow release of the note.

Auto Populated Fields – the fields in this area will auto populate when header information is saved.

Inpatient – check here if the client is an inpatient in your facility.

Admitted – the date the client was admitted as an inpatient.

Discharged - the date the client was discharged as an inpatient.

Tabs:

Brief Mental Status Exam (comes with PIMSY) - set up by the system administrator prior to doing your notes. There is one pre-loaded in the PIMSY system or it can be changed to better serve your practice’s needs.

Goal – all active goals previously created in the treatment plan are available in this tab to be brought into the note body.

Add. Services – is where you add any additional services provided and PQRS codes as needed.

Addendums – in order to add or change a note after it has been released, an addendum must be performed. You cannot modify a note directly once it has been released.

Team – this area is used for team notes or when multiple clinicians are needed for signoff.

Reference – information only tab that reflects what insurance is attached to the note as well as note release info. Includes a Diagnosis box where you can view what diagnoses are on the client without leaving the Note.  The Diagnosis will only show after you have saved the note for the first time.

Misc Q & A Tracking – optional Q&A area that is set up by the company Administrator.

Instructions:

CREATING A NEW NOTE

To start a progress note for a client, go to the appointment in the SAL/Calendar and open it.

Click on the Note button. A box will pop up where you select the type of note you need. Select New Therapy / Progress Note. Click OK.

This will open the Note box which will have the date, time, duration, and billing code already pre-populated. The Location code and Division will auto-populate if previously set on the client’s chart. This demographic info that is attached to the note is referred to as the Headers. Once the Headers are selected or pre-populated for the note click Save. From this point in the note documentation process, before the note is released, the staff performing the note can save their work, exit, and finish at a later time.

The Note section is where you type the actual note. This can be free text or right-click and select Templates in order to access a list of pre-defined Templates that are set-up by the company administrators within the Pick List. The Note Type drop-down list contains note outlines to aid in documenting appropriately.

The bottom portion of the Note dialogue box includes seven tabs. In the Goal tab, the previously established needs and goals that were input into the Treatment Plan are shown here. To bring a goal into the note, select the appropriate row from the Goal tab. If you double-click on the entire row it will bring in the entire goal. If you just want one part from the goal list, double-click on that one cell.

Once the note is complete, click the Released box (Release = Sign Off). Releasing the note locks the note from any further changes (for audit purposes). Prior to Release, the note can be Saved and edited as many times as needed. Once the note is released, the note is locked, and requires an Addendum (see above), to be changed.

The Answers button is for quickly copying answers from any Q&A form in the client's chart. To use this feature, click on the Answers button and select a Q&A in the drop-down list. Select Include Dates or Include Title and Headers if desired. The Q&A answers are now copied to the system clipboard on your computer. Click inside the Note where you want the answers to appear and right-click/paste.

Use Case:

Dr. Holbrook at ABC Therapeutics has just seen a client and needs to write a note for the visit. He goes to the My Sal Calendar and opens up the appointment for which he needs to write the note. Dr. Holbrook completes much of the relevant information but doesn’t have time right now to complete the note. He saves the note for now so he can go back later to finish and release the note for billing.

Related Articles:

If you cannot find what you need in this article, please contact Support (email) or call 877.334.8512 ext. 3

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