Documenting a Group Note from the Home Page


  1. Within the “Client List” select the List that contains all the users that will be part of the group note, by checking the checkbox next to each client’s name.
  2. Then select “Group Note” from the “Action on Selected Clients” dropdown menu.
  3. The “Group Progress Note” page opens. Complete the group note, by filling in the “Interaction Start date/time & End date/time”, and all fields that apply for the group itself.
    1. Note: do not include any specific client information on this page as this will be reflected on all client’s chart. Once the Group note is created you will need to individualize the note and this is where you can include any client specific information.
  4. Next you will add your Workload for this group appointment by clicking “Add Workload”. 
  5. Complete the workload by updating the following information as applicable.
    1. Please select a client from the group: Leave this field as “All Client” so that the Workload is divided and added to each individualized client note
    2. Program: select the program that the clients are a part of
    3. Site: if applicable chose the site the group took place, otherwise, leave blank.
    4. Direct Mins: should be prepopulated with the number of minutes that you entered in the “Interaction Start and End Date / Time”
    5. Ex: If your visit was from 10:00am to 11:00am, then you will see 60 in this field
    6. Direct Date: should be prepopulated with the date that you entered in the “Interaction Start and End Date / Time”
    7. Direct WL Type: This should be prepopulated to “Therapeutic”
    8. Visit: this should be prepopulated as “1”
    9. Visit Type: select the visit that reflects the group you completed i.e. “face-to-face office”
    10. Grp. Session: Enter “1” in this field so that this is captured in your statics as a group
    11. Indirect and Non-Clinical: If applicable, enter in the minutes, date and type for any Indirect or Non-Clinical work you completed in relation to this visit.
    12. Ex: 30 minutes of “Travel” time under “Non-Clinical”
    13. Click “Save” to add the workload to this group note.
  6. Complete the Group Note by clicking the “Save Note” button to save a copy of the note to each selected client’s record.
  7. When the Group Progress Note is saved, you will be brought back to the Home Page. To individualize each of the clients group notes, click on the “Group Notes to be Completed” link under the “Progress Notes Notifications” pane which will take you to the “Incomplete Group Session Notes” page.
    1. Note: You can also access these notes from the Progress Notes page by clicking on the “Group Note(s) to be completed” link in the top left.
  8. Once you are on the “Incomplete Group Session Notes” page, click the [+] button to expand and view the details of each note. Then click the “Edit Icon” to edit and complete the individualization of the group note.
  9. The Individual Group Progress Note page will then load with the following information will already be completed for you, but you will need to create an encounter for each if the individual client notes.
    1. Interactions Start and End Date / Time
    2. Workload: This will be already be added to the note with the information you entered on the group note and the time divided equally by the number of participants. 

 


Create an Encounter


  1. From here you will either be “Copying an Encounter” or “Creating a New Encounter”.
  2. Click on “Show discharged/other encounters”, to display all encounters for this client.
  3. If there is a previous encounter listed that is similar to the one for this visit (i.e. “An activity encounter”), then you can copy that encounter to create a new one for this visit. If there is not a similar one, then you will want to create a new one.
    1. Note: If this is the first time you’ve done a visit with the client you will only see their enrollment encounters, so you will want to select “Create New Encounter”
  4. Copying an Encounter
    1. With the list expanded, find the encounter that closely matches the visit you have competed with the client. Then click on the copy icon to create your encounter for this visit.
    2. The “Create New Encounter Copy” module will launch, and will be pre-populated with the same date as you entered the “Interaction Start and End Time”. Review the following fields, and update as needed and then click save.
      1. Admit date & End Date:  should be the same as you Interaction Start and End Date
      2. Visit Type: should be “Activity”
      3. Encounter Type: If different than the copied encounter, select the appropriate type for this visit
      4. Program: Select the Program that the client is enrolled in for this visit
      5. Primary Clinician: If not your name, enter your own name.
      6. Status: If different than the copied encounter, select the appropriate status for this visit.
      7. Click Save
    3. The page will reload with your new encounter selected. The encounter number will be listed as “NEW” until you’ve completed and signed your progress Note.
  5. Create New Encounter
    1.  If there are no other “Activity” encounter listed, click on “Create New Encounter”.
    2. The “Create New Encounter” module will launch, and then you will complete the following fields;
      1. Admit date and End Date: should be the same as your “Interaction Start and End Date”
      2. Visit Type: should be “Activity”
      3. Encounter Type: Select the appropriate type for that visits
      4. Program: Select the Program that the client is enrolled in for this visit
      5. Primary Clinician: Enter your name
      6. Status: should be “Attended”, but could also be “Cancelled” or “No-show”
      7. Then click “Save”
      8. The page will reload with your new encounter selected. The encounter number will be listed as “NEW” until you’ve completed and signed your progress Note. 
      9. Complete your Progress Note, by filling in all fields that apply and adding any additional information that applies to that specific client. I.e. Participation level during the group
      10. Click the “Sign Note” button to save the Progress Note.
      11. Complete the same process for the remaining group Note that require individualization.


Note: Mandatory fields are denoted by a red asterisk (*).