Overview
The Notes to Start Dashboard Tile in the Portal offers a quick and convenient way to begin notes for past appointments or sessions. Notes give clinicians a structured format to document client evaluations, track progress, and record clinical observations. They may include observations, treatment recommendations, and other relevant details, all securely stored within the client’s chart.
Required Permissions and Prerequisites
- This article is in reference to our Portal
- Please assign the Create, Modify, View, and Delete permissions for the following rule(s):
- Note (Assessment)
- Group Notes
- Note Progress View
Step-by-Step Instructions
Step 1: Step 1: Navigating to the Notes to Start Tile
When logging into the Portal, you will land on the Dashboard. From the Dashboard, select the Notes to Start tile.
Step 2: Viewing the Notes to Start Tile
The system automatically detects appointments that have occurred, that do not currently have a note generated. These appointments appear in the Notes to Start tile as a list for easy access. All listed notes will display the associated SAL #, Billing Code, Client, Status, Service Date, Service Time, and more from the appointment.
Step 3: Creating a New Note
To create the note, click the Create button underneath the Action column. This will open the associated appointment.
Next, verify the appointment information and then click the Note button to open the note dialogue.
From the note screen, you must have a billing code, start and end time, and location code to perform the initial save. This generates a note number and starts the auto save feature. Once you have the note number, you can begin to make edits. The note will no longer show under the Notes to Start tile, as it has now been started.
Check whether the session was Inpatient, Face to face, or a Collateral Note. Complete forms from the Select Forms dropdown and view or edit Tags.
Additionally, you can view and edit the following areas at the top:
-
Substance Usage – Record and track substance use
Medications – View and manage client medications (can be used with eMAR)
Diagnosis – View and manage diagnoses
Goal – View and manage goals and outcome measures
Add Services – Add additional services such as prolonged service codes, crisis codes, etc.
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.
Once all information has been entered and verified for accuracy, the user can check the Release for Review box.
Once the note has been marked as Reviewed, the user or supervisor can release the note, depending on setting -122.
For sites that do not utilize supervision, or if the clinician does not need a reviewer, they simply check the Released box. Marking a note as "Released" locks it from further editing, attaches your digital signature, and indicates it's ready to be billed.
Step 4: Docking Notes
Once a note has been started, you may click the pin icon in the top right corner of the note, which will place this note in the docking station.
You can move on to other tasks, or log out completely, and when you are ready to return to the note, simply click the docker menu.
This will expose your list of notes that are docked. To resume working on a note, click on the note in the list.
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