Service Notes are notes that document meetings and other contacts with a consumer, the consumer's family or service staff. These notes are recorded in the service notes portion of a consumer's records in HCSIS. Service Coordinators should strive to create Service Notes that give a professional, accurate, unbiased and objective picture. This tip sheet describes the process used to enter Service Notes into HCSIS. 1 Create Service Notes All users should review the following steps before entering service notes in HCSIS Navigate to the Service Notes screen by following the menu path: SC > Service Notes > New Service Note. Search for the consumer using one of the search fields. Last Name First Name: When searching by First Name, the Last Name field is mandatory. Click [Search]. Identifier Type: Either SSN or MCI#. Selecting an option in this field will make the Identifier field mandatory. Identifier: Enter either SSN or MCI # When the Date of Service/Contact field shows 10/01/2015 or later, OR if no date is entered, an ICD-10 code appears here. When the Date of Service/Contact field shows 09/30/2015 or before, an ICD-9 code appears. Date of Service/Contact (MM/DD/YYYY): Date the consumer was contacted or another task was completed for the consumer s file. This contact may be a meeting or a telephone conversation. Be sure to note the callout in the screenshot above. Location of Service: Select the location of service: SC Entity Office Individual s Home Community Service Type: Select the type of service note: Locate: An activity that links a consumer to a service. Coordinate: An activity that entails interaction with others. Monitor: An activity that entails ongoing evaluation and assessment of current services. TSM Transition Activities: [OLTL does not use this service type.] Other/Non-billable: An activity not covered by the other options available. Important: All users are expected to begin using the Service Notes screen immediately, instead of the Meeting Details or Contact Log screens, to capture meetings and contacts with consumers. : 1
1 Category: Select the category that best describes the activity of the service note: Create Service Referral: Intake/referral for a service. Note cont d Plan: Development, implementation or review of a plan. Eligibility: Determination of eligibility for services. (Financial and Program) Budget: Planning/implementation/review of fiscal matters. Health and Safety: Evaluation and assessment of the consumer s support systems and environment. PUNS: This should be selected by OMR only. Case Transfer: Transferring service responsibility from one person to another. SC Individual Monitoring: Compliance monitoring and quality assurance Daily Living: Assessment of daily activities such as bathing, cooking, etc. Respite: Providing services to individuals on a short term basis in the absence or need for relief of persons normally providing care. Vocational: Job related services Adult Day: Health and social services furnished in an outpatient setting. Educational: Special education and related services as defined in the Individuals with Disabilities Education Act (IDEA). Community Integration: Assisting individuals in acquiring, retaining, and improving self-help, socialization and adaptive skills necessary to reside in the community. PERS: An electronic device that enables an individual at high risk of institutionalization to secure help in an emergency. Environmental Adaptation: Physical modifications to the home required by the individual s plan of care. Assistive Technologies/Specialized Medical Equipment: Devices, controls or appliances which enable individuals to increase their abilities to perform activities of daily living. Extended State Plan Services: Physical, Occupational, and Speech Therapy, Parttime Nursing, and Visiting Nurses services. Transportation: Enabling consumers served on the waiver to gain access to waiver and other community activities. Other: An activity not covered by any of the other Categories listed in the Service notes screen. OLTL - Plan Increase: Activity that focuses on the addition or increase of services to a plan due to a participant s change in need or condition. OLTL - Plan Decrease: Activity that focuses on a decrease in services to a plan due to a participant s change in need. OLTL - Temporary Plan Increase: Activity that focuses on an increase or decrease in services to a plan that will last temporarily or less than 120 days due to a participant s change in need 2
1 Create Service Note cont d Sub-Category: Select a sub-category that best describes the service for the service note: Agency: Agency activities Base Mental Retardation Case Management: This option is used by OMR only Determination: This option is used by OMR only Development/Revision: Development or revision of a consumer s plan Employment Services (Competitive Employment): Services which link consumer with job training and placement. Employment Services (Supportive Employment): Services which link consumer to supportive assistance on job site Home and Community Services: Services in the home or community setting. Incident: Reporting of an incident involving the consumer Personal Assistance Services: Services that support ADL needs Personal Support Services: Services that support life skills development Prevocational: Services that support preparing a consumer for paid or unpaid employment but are not job-task oriented. Recertification: Waiver/program recertification Respite Services: Substitute caregiver responsibility for a defined period of time. Specialized Supports: As defined for both waiver and non-waiver services; examples include therapies Nursing Service, Dental and Nutritional Consultation. Supported Integration: Services designed to assist consumers in acquiring, retaining, and improving self-help, socialization and adaptive skills necessary to reside in the community. Also referred to as community integration. TSM - Base: This option is used by OMR only TSM - Consolidated Waiver: This option is used by OMR only TSM - Person Family Directed Waiver: This option is used by OMR only Therapies: Services which provide various therapies, examples include PT, OT, Speech/Language Therapy, Behavior Therapy and Visual/Mobility Therapy. Transportation Services: Services that facilitate community mobility. Vendor Services (No ITQ Services): Services that are outsourced to the consumer. Visiting Nurses: Nursing services such as visiting nurses or private duty nurses. Other: Activities not covered by any of the other Sub-Categories OLTL - Education Services: Services that consist of courses that help the waiver participant in acquiring, re-learning or re-gaining skills and knowledge. OLTL - Community Integration: Service that is short-term, goal-based support designed to assist participants in acquiring, retaining, and improving self-help, communication, socialization and adaptive skills necessary to reside in the community. OLTL - Accessibility Adaptations, Equipment, Technology and Medical Supplies: An item, piece of equipment, or product system, whether acquired commercially, modified, or customized, that is used to increase, maintain, or improve functional capabilities of participants. OLTL - Service Coordination: Services that will assist individuals who receive waiver services in gaining access to needed waiver services and other State Medicaid Plan services, as well as medical, social, educational and other services regardless of the funding source. OLTL - Adult Daily Living: services provided to meet the personal care, social, nutritional, therapeutic, educational, and recreational needs of individuals in a licensed center. OLTL - Personal Emergency Response System: Service includes an electronic device which enables waiver participants to secure help in an emergency. The individual may also wear a portable help button to allow for mobility. The system is connected to the person s phone and programmed to signal a response center once a help button is activated. 3
1 Create Service Note cont d No. of Units: This option is used by OMR only. Follow-up: Determine whether a follow-up is needed. Follow-up Due Date: Enter the due date for the follow-up information. This field is mandatory if the Follow-up field is marked <Required>. If this date passes before a follow-up service note is entered for this service note, an alert will be sent to the SC. Service Note: Enter the service note information. Service notes document meetings and other contacts with a consumer, their family, or other service staff. Service notes should be focused on the service provided, not personal information about the consumer. Service notes should follow a standard format. They should include the time of the contact, your initials and then the detailed text of the note. Service notes can include a maximum of 4000 characters. Click [Save]. When writing Service Notes: Write Objectively: Document what happens, what is said, and what is observed. Service Notes are not meant to be a record of your emotional reaction to a particular situation. Avoid judgmental terms and descriptions. Write Clearly: Be objectively descriptive. It will help you be precise about what you are describing. Try to avoid vague or general terms. Write So Others Can Understand: Thoughts are communicated more effectively with simple and direct words than with technical jargon. Write Using People First Language: When describing people and their disability, identify the person first and then the disability. The disability represents only one of many characteristics of the person. 4
2 Review Service Navigate to the Service Notes screen by following the menu path: SC > Notes Service Notes > Search. Note: When searching for a service note in HCSIS, the default search date range is 31 days. To expand the search to view notes up to a sixmonth timeframe, enter the relevant date range and specify either the individual s first and last names or the identifier type and identifier. You can search for Service Notes using the following criteria: Last Name First Name From Contact Date To Contact Date Identifier Type Identifier Caseload View: Choose one of the following view types: Follow-up, Summary, Text Sort by: Sort the search results by the Date of Contact, Date of Entry or Consumer Name. Click [Search]. Review the information in the service notes. Click on the note hyperlink for the service note that you want to review. 5
3 Advanced Service Note Search Navigate to the Service Notes screen by following the menu path: SC > Service Notes > Search. Using the menu path above, navigate to the Service Notes screen. Click [Advanced Search]. Use any of the following fields to search for service notes: Last Name First Name From Contact Date To Contact Date From Entry Date To Entry Date Identifier Type Identifier Comment Author Last Name Comment Author First Name Category Subcategory Caseload Service Type Sort by View Click [Search]. Note: When searching for a service note in HCSIS, the default search date range is 31 days. To expand the search to view notes up to a sixmonth timeframe, enter the relevant date range and specify either the individual s first and last name or the identifier type and identifier. 6
4 Edit Service Notes Search Service Coordinator Navigate to the Service Notes screen by following the menu path: SC > Service Notes > Search. Review the information in the service notes field. Make any changes to the service note fields as necessary per your review. For clarity, enter a description of what you have changed on the service note in the Supervisory Edit field. Click [Save]. All notes and edits may be updated from the day they are entered until the 4th or 19th of that month. Service notes become read-only on the 5 th and 20 th of the month. 7
4 Plan Screen Updates Add Service Note Review Service Notes Navigate to the Plan screens by following the menu path: Plan > Services and Supports >Service Details. The [Add Service Note] and [Review Service Notes] buttons have been added to the Plan s Service Details screen. SCs can click [Add Service Note] to open service notes in a pop-up window for editing. OLTL reviewers can click [Review Service Notes] to open service notes in a pop-up window and view the consumer s recent service notes. All notes and edits may be updated from the day they are entered until the 4th or 19th of that month. HCSIS runs a program that makes service notes read only every 15 days. After 180 days the entire service note is read only. 8
4 Service Notes Pop-up window The new Service Notes pop-up window contains the option to search for service notes based on dates. A maximum of a six-month period is viewable at a time. Users can navigate to the next six-month period by clicking [Next 6 Months] on the lower right side of the screen. Service Notes may be printed by clicking on the hyperlink in the Comments column which displays in another pop-up window. Click PRINT THIS SERVICE NOTE located in the upper left of the window to print the Service Note. Once updating/reviewing the service notes is complete, the user may close the pop-up window to continue editing/reviewing the plan. All notes and edits may be updated from the day they are entered until the 4th or 19th of that month. HCSIS runs a program that makes service notes read only every 15 days. After 180 days the entire service note is read only. 9