Documenting a Progress Note from the Progress Notes Tab

The following QRG outlines how staff can document their progress note via the Progress Notes Tab. Staff can either input their appointments prior to seeing the client or they can do them as they occur.

1. With the client selected, navigate to the Progress Notes page.
2. On the Progress Notes Page, select the note you would like to create from the drop down menu, and then select the “Create” button.
   1. Input the “Interaction Start Date & Time” and the “End Date and Time”

   2. 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.
         3. Admit date & End Date:  should be the same as you Interaction Start and End Date
         4. Visit Type: should be “Activity”
         5. Encounter Type: If different than the copied encounter, select the appropriate type for this visit
         6. Program: Select the Program that the client is enrolled in for this visit
         7. Primary Clinician: If not your name, enter your own name.
         8. Status: If different than the copied encounter, select the appropriate status for this visit.
         9. Click Save
         10. 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” encounters listed, click on “Create New Encounter”.
            1. 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.
3. Then you will complete the rest of your Progress Note by filling in any mandatory or relevant details.Next you will add your Workload for this visit by clicking “Add Workload”. 
4. Confirm if the pre-filled information is correct, enter any additional information as needed then save the Workload.
   1. Program: should be pre-populated with the program that you entered into the appointment
   2. Site: if applicable chose the site the appointment took place, otherwise, leave blank.
   3. Direct Mins: should be pre-populated with the number of minutes that you entered into the appointment
   4. Ex: If your visit was from 10:00am to 11:00am, then you will see 60 in this field
   5. Direct Date: should be pre-populated with the date that you entered into the appointment
   6. Direct WL Type: This should be pre-populated to “Therapeutic”
   7. Visit: this should be pre-populated as “1”
   8. Visit Type: This should be the same visit type you entered in the appointment i.e. “face-to-face home”
   9. 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.
5. Complete this Progress Note by clicking “Sign Note”