Overview
Clinical Notes in PIMSY provide clinicians with a structured way to document client evaluations, track progress, and record clinical observations. Notes can include observations, treatment recommendations, and other relevant details, all stored securely within the client’s chart. By centralizing this information, PIMSY ensures that clinical notes are easily accessible for ongoing care, provider collaboration, and compliance with documentation standards.
Required Permissions and Prerequisites
- This article is in reference to our Desktop application
- Please assign the Create, Modify, View, and Delete permissions for the following rule(s):
- Note (Assessment)
- Group Notes
- Note Copy
- Note Documents
- Note Team
- Note Modify Admin Save Button
- Notes Can Allow Unconditional Release
- ...Note Billing Tags
Step-by-Step Instructions
Step 1: Navigating to Clinical Notes
Clinical Notes can be accessed from multiple areas within PIMSY, such as the SAL Calendar, Client Chart, and the global Notes option under the Clients menu.
For this article, we will be looking at Clinical Notes from the SAL Calendar.
From the top navigation menu, go to:
Utilities > SAL > My SAL Calendar
Step 2: Creating a New Clinical Note
From the calendar, select the appointment you want to create a new note for. In the Edit SAL window, click the Note button.
From the popup, select New Assessment / Medical Follow-up Note and click OK.
This opens the Note window for the selected client and appointment. The note header is the first section of the note and must be completed to initiate a Note #. The necessary data points are Service Date, Time, Duration, and Billing Code. This data will carry over if filled out from the sal. The Location Code and Division will also auto-populate (on the save) if they were previously set as defaults in the client’s chart. Check the In Clinic box if the appointment was in clinic, Face to Face when seeing the client in person, or for telehealth services, select if it was done via video or audio only. Once these filled are completed, click Save to generate a note number, and enable PIMSY's autosave feature.
Once a note number has been generated, the note will now show in the Unrel. Notes dashboard tile until it is released. "Unreleased" means the note has not been signed off and can still be edited.
From this point in the documentation process until the note is released, staff can edit and save their work, exit, and return later to complete it. Data from the note will sync back to the SAL appointment, so any edits must be made to the note - not the appointment.
Please note, once a note has been created, the note becomes the source of truth, so any changes that may need to be made to the date of service, billing code, duration, etc. must be done within the note, and not the SAL.
Step 3: Clinical Note Options and Tabs
Within a note, there are several features and tools available:
- Note Report – Generate a report of the note
- Docs – Assign and View documents linked to the note
- View Client – Open the client’s chart
At the bottom of the note screen, you’ll find a series of tabs (some configured by your PIMSY Administrator through the Q&A Pick List):
- Client Vitals – Record and track client vitals
- Forms – Access clinical Q&A forms and generate narrative with PAISLY AI
- Substance Usage – Record and track substance use
- Medications – View and manage client medications (can be used with eMAR)
- Diagnosis – View and manage diagnoses
- Add. Services – Add additional services
- Goal – View and manage goals and outcome measures
- Addendums – Manage note addendums on released notes
- Team – Assign and manage team members
- Reference – Quick view of demographics, insurance, and service location info
- Misc Q&A Tracking – Area for internal notes and comments, such as sending back supervision notes that have been released for review, for corrections.
Step 4: Releasing a Note
Once all information has been entered and verified for accuracy, the provider can simply check the Released box.
For sites that utilize supervision, or if the clinician needs a reviewer, the user can check the Release for Review box. A supervisor can then review the note and request any necessary edits. If no edits are required, the supervisor checks the Reviewed box.
Once the note has been marked as Reviewed, the user or supervisor can release the note, depending on setting -122.
PIMSY will do a final comparison of data points, settings, and requirements to ensure compliance prior to release. If there are required fields that are missing (according to your site's configurations), PIMSY will prompt you with an alert of what must be corrected.
Marking a note as "Released" locks it from further editing, attaches your digital signature, and indicates it's ready to be billed.