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Assessment 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 Assessment Notes.

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

Tabs:

In the bottom portion of the Assessment note dialogue box are the Assessment Tabs. The first 7 tabs are specific to your practice – your PIMSY Administrator will set them up in the Q&A Pick List.

Instructions:

To start an Assessment Note for a client, go to the appointment in the My SAL/Calendar and open it.

Click on the Note button.

This box will appear:

Choose New Assessment/Medical Follow-up Note and click OK.

This will open the Note box which has the date, time, duration, and billing code 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, Save. From this point in the note documentation process, until the note is Released, the staff performing the note can save their work, exit, and finish at a later time.

Use Case:

Therapist Jane has performed a Comprehensive Clinical with her new client, Bob. It is time for Jane to document the service accordingly.

Jane pulls up her calendar and opens up the applicable appointment for Bob. She clicks on Note, New Assessment Note, and the Assessment Note dialog box opens up.

Jane checks that all of her header information is correct and then proceeds to document her interaction with Bob according to the CCA service definition. Once completed, she releases her Assessment Note and goes on about her day.

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