With PIMSY, documenting group service notes is made simple. When a Group Note is documented, the system creates the individual notes for the designated group members, thereby saving the clinician time and effort.
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 Group 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
Fields on the top left side:
On the left side of the window is an area to manage members of the group. Double-click on a name in the top to assign a client to the group note.
Fields in the top middle area:
Description – optional group description
Service Date - the date the service was performed
Duration – length of the session
Location Code – where the service was performed
Billing Code – group billing code
Face to Face – check this box if the service was performed face to face
Collateral Note – Check if the session included collateral contacts
Division - if your practice has divisions, you can select the appropriate one here
Note Type – predefined template for the group note
The following fields will be automatically filled when the note is saved:
- Created Date
- Created By
- Last Edited Date
- Last Edited By
Fields in the top right area: All fields in this area will be auto populated when the note is saved.
Fields in the bottom area:
The top part is a list of the notes for each individual client. This is auto-populated when you Generate/Update Notes. Double-click on a line to view the note for that client. This is also where you Release a note or Release for Review if dual sign-off is required.
Generate/Update Notes - use this button to generate or update the individual notes once you have saved the group note portion. The lower part of the screen will populate with the most recent group note for all members of the group.
View Clients - You can view an individual client's chart directly from the group note window.
ABC - This is a helpful spell-check option for the body of your note.
Addendums – When a note has been released, it is locked from editing. However, you can add Addendums to a note if there are changes or additions to be made. Select the Addendum button in order to make the Addendum section visible below the individual notes grid. There is a Save Addendum button in the Addendums area since you won't be able to use the normal Save button at the top of the screen.
Take a Payment - to take a payment for a group, click the Group Note button in the appointment window and select the name of the client in the bottom left section. Click the Take a Payment button (bottom left column) in the assigned client’s box. This will let you take payments individually for each client.
Export - This button appears in many areas of PIMSY where you can export a file to MS Excel.
View Note - Use this button to view the actual note.
Attach Note - This is where you can attach the current note to another existing note.
Open the SAL appointment and click on the Group Note button.
There are other areas where you can access Group Notes, such as under the Notes tab in the Client Details window or from the Home page.
This box will appear:
Select an existing Group Note and click on View Note Group button or click on New Note Group to create a new one.
To assign a client, double-click on the name in the top box Unassigned Clients to move it to the Assigned Clients box below.
NOTE: when you remove a client from a group note, it will prompt you to make a SAL appointment for that user with a status of No Show, Cancelled, Rescheduled or Don't Create Attendance SAL Record. This allows you to easily track the client's attendance in that program.
The clinician has two options to Unassign clients from a group:
Option one is to access the Group Note and double-click a client in the Assigned box to Unassign. A box will pop up that allows you to select No Show, Cancelled, or Rescheduled. When you make a selection and click OK, PIMSY automatically adjusts the appointment in the calendar.
Option two is leave the client in the group and when the clinician generates and accesses that individual note they can then change the CPT code to NO Show.
When you go back to the calendar, be sure to uncheck the Hide Cancellations box to see the auto-created entries.
If someone was invited, but is not a normal participant in this group, they can be added by double-clicking their name from the Unassigned Clients list (top box).
From the Group Note window, start the Group Note, making sure the Service date is correct along with Location code, and Billing code. You can add a description at the top if you like. In the large Notes box, type the generic portion of the note that will generate into every group member’s individual note. Click Save. If there are any errors, the system will let you know.
Then click the Generate/Update Notes button at the top of the screen.
The appropriate Note Headers will auto-populate.
In order to add the individual portion to each group member’s note, double-click the appropriate row at the bottom of the window and their Progress Note will open.
In the note body, free-type the individual portion after the ***End Group Section*** text that appears.
When this is completed, the note is ready to be Released or Released for Review. If needed, Repeat the steps above for each client in the group.
Notes must be released individually by checking the box for Released or Released for Review.
ABC Therapeutic Group is offering an evening SA Group for their clients starting this Friday night. A group appointment has been created in the SAL calendar and scheduled with Sally, a therapist for ABC.
After the group session, Sally opens up her group appointment and creates a group note. She assigns clients to the group note according to who attended the group, and then documents her group session. Sally generates her individual notes, adds whatever pertinent individual information is necessary to each note, and then releases each individual note.
Sally has now documented an individual group session note for each attendee quickly and efficiently.
If you cannot find what you need in this article, please contact Support (email) or call 877.334.8512 ext. 3.