Reviewing Service Notes

6 Reviewing Service Notes Course Map SC SC Supervision Supervision 1. Overview 1. Overview 2. Creating and Maintaining an SC 2. Creating and Maintaining an SC Entity Entity 3. Creating an SC or SC 3. Creating an SC or SC Supervisor Profile Supervisor Profile 4. 4. Creating Creating Caseloads Caseloads 5. Assigning New Individuals to 5. Assigning New Individuals to an an SC SC 6. Reviewing Service Notes 6. Reviewing Service Notes 7. Performing Transfers 7. Performing Transfers 8. Maintaining SC Profiles and 8. Maintaining SC Profiles and Caseloads Caseloads 9. 9. Creating Creating SC SC Supervision Supervision Reports Reports 10. 10. Using Using the the Start-Up Start-Up Screen Screen 11. Course 11. Course Review Review Objectives At the completion of this lesson, you will be able to: Describe why the SC Unit Manager and the SC Supervisor add clarifying comments Read service notes to verify TSM billable units Add clarifying amendments to Read-only service notes previously entered about an individual Reviewing Service Notes Version 3.1 6-1

SC Supervision Process Flow Supervisory Functions (daily activity) Maintain SC Entities and Profiles in HCSIS (as needed) Perform Case Transfers (as needed) Alerts, Notices and Reports are used throughout. Supervisory functions are the main activities of the SC Supervision roles. Tasks include reviewing service notes for quality and clarity, adding comments when necessary, and reviewing the accuracy of TSM billing units. Supports Coordinators will spend most of their time in HCSIS doing service notes. This area of the system will store and retrieve all service notes and TSM timekeeping logs. One standard service note and timekeeping log will be used for all individuals, regardless if they are TSM billable or not. SC Supervision roles can use HCSIS to review service notes. They can search for comments based on service type, social security number, TSM billable comments, comment author, and so on. Flow Legend White. Squares shaded in white are in the course but not in the lesson. Medium grey. Squares shaded in medium grey are in the process but not in the course. Blue (may appear as dark grey). Squares shaded in blue (dark grey) are the lesson currently being discussed. Reviewing Service Notes Version 3.1 6-2

Key Terms and Concepts Follow-up Service Notes The Follow-up Service Note allows the Supports Coordinator to set reminders for follow up to service notes; for example, to remind them to follow through on a finding during a monitoring. In addition, Follow-up Service Notes may be used for monitoring visits for individuals who do not adhere to the standard monitoring frequency requirements based on funding source and residential setting. If the date when the follow-up was due passes before a follow-up service note is entered, an alert will appear for the SC. Service Note Service Notes are notes that document meetings and other contacts with an individual, the individual s family, or other support staff. These comments are recorded in the service notes portion of an individual s record in HCSIS. It is recommended that service notes generally begin with a descriptive phrase, such as: Face to face with Conversation with Facilitated Individual Support Plan (ISP) meeting Call to/from Waiver monitoring at Facilitated team meeting Team meeting at Typed ISP Continued typing ISP Peer review with Supervision with Reviewed and filed notes from Completed referral packet for When recording service notes, remember to be specific and to the point, include facts only (not opinions), and specify all relevant dates. Reviewing Service Notes Version 3.1 6-3

Key Terms and Concepts (continued) Service Note Views Service Notes may be displayed using several different views. Follow-up required service notes only: The Follow-up Service Note view provides a list of any Service Notes requiring follow-up action to be taken. This listing displays only Service Notes for the individuals in the Supports Coordinator s caseload. TSM Activity (MA Eligible consumers only): The TSM Activity Service Note view provides a list of service notes for the individuals in the caseload that are eligible for TSM billing. Summary: The Summary Service Note view displays only the following fields for each retrieved comment: Date of contact, Comment, Supervisory edit, and Date last edited. The number of service notes displayed on a single page is limited to twenty. Users may click on the [Edit Comment] button to open a selected comment in the Service Note pop-up window. Text: The Text Service Note view displays the comments in a table format with several fields from each of the service notes (Date, Location, and a few words from the comment). Comments are grouped by individual name alphabetically. Target Services Management (TSM) Target Services Management (TSM) is a funding stream for Medical Assistance eligible persons. TSM assists individuals in gaining access to needed waiver and other state plan services, as well as medical social, educational and other services, regardless of funding source. TSM includes the development, location, coordination and ongoing monitoring of the provision of services included in the individual's plan. Reviewing Service Notes Version 3.1 6-4

Reviewing Service Notes Task Flow 1 2 3 SC Supervisor or SC Unit Manager logs into HCSIS and reviews case comments. SC Supervisor or SC Unit Manager makes supervisory edits as appropriate. Supports Coordination role reviews supervisory edits from their supervisor. Reviewing Service 1. As a supervisory function, the SC Supervisor or SC Unit Manager reviews service notes entered by the SCs they supervise. 2. After reviewing the service notes, the SC Supervisor or SC Unit Manager adds any clarifying amendments and/or additional service notes. 3. The SC reviews the edits and additions made by their supervisor. Roles: The SC Supervision role is responsible for reviewing and/or editing the service notes entered by the SCs they supervise. The SC Unit Management role can also review and edit service notes. The County SC Oversight role has read only access to the existing service notes but they can add their own service notes. Reviewing Service Notes Version 3.1 6-5

HCSIS System Task(s) The following screens will be used in this lesson: Service Notes screen Service Notes Advanced Search screen Reviewing Service Notes Version 3.1 6-6

Demonstration 6-1: Review Service Notes This demonstration reviews the process of reviewing service notes entered by SCs. The SC Supervision role is responsible for: Reviewing the service notes entered by the SCs they supervise. Adding supervisory edits to the service notes entered by the SCs they supervise. The SC Unit Management role can also review and add supervisory edits to service notes. The County SC Oversight role has read only access to the existing service notes, but they can add their own service notes. To become familiar with this process, use the following steps: Menu Path: SC SC Service Notes SC Service Notes Search Steps: 1. Using the menu path, navigate to the Service Note Search screen in HCSIS. Reviewing Service Notes Version 3.1 6-7

Demonstration 6-1: Review Service Notes (continued) Steps Continued: 2. Use any of the following fields to search for service notes: Field Last Name First Name From Contact Date To Contact Date Description Enter the last name of the individual whose service notes you want to review. The search will not work if the name is not spelled correctly. Enter the first name of the individual whose service notes you want to review. The search will not work if the name is not spelled correctly. Narrows the search to include only those comments created on or after the date entered in this field. A suggested date will default in this field. Narrows the search to include only those comments created on or before the date entered in this field. A suggested date will default in this field. Identifier Type To search by an individual s social security number, select SSN from the drop-down list. To search by business service unit, select BSU# from the drop-down list. Note: If this field is used, the Identifier field will require an entry. Identifier Caseload Sort By View Enter the social security number or business service unit number, as indicated in the Identifier Type field. Narrows the search to a specific SC s caseload. Sorts the Service Notes Search results in descending order by one of three criteria: Consumer Name Date of Contact Date of Entry Narrows the search to show only a certain type of service note. Choose one of the following view types: TSM Activity only displays service notes for individuals who are MA eligible Follow-up only displays service notes flagged for a follow-up with the individual Summary displays service notes in a summary format Text displays the text in the service notes This is a required field. Tip: The default timeframe for searches is 31 days. In our example, a Service Note was entered on 5/13/2004. We are searching with the timeframe of 5/1/2004 5/30/2004. To expand the search to view records 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. Note: The next demonstration in this lesson demonstrates a more advanced search. Reviewing Service Notes Version 3.1 6-8

Demonstration 6-1: Review Service Notes (continued) Steps Continued: 3. Enter the first and last name of a consumer in the caseload. 4. Click [Search]. 5. Click the comment hyperlink for the comment that you want to review. 6. Review the information in the service notes. 7. Make any changes to the Service Type, Category, Sub-Category, No. of Units or Billable checkbox regarding the service note. Note: To change the billable status of the case, click or unclick the checkbox to the left of the Billable field. If a service note is marked billable, its Service Type must be either Locating, Monitoring or Coordinating and the individual must be MA eligible. Tip: Click the hyperlink to view the comments. If there are no comments for an individual, the hyperlink will say NO COMMENTS. Reviewing Service Notes Version 3.1 6-9

Demonstration 6-1: Review Service Notes (continued) Steps Continued: 8. Type supervisory edits for clarity in the Supervisory Edit field. Note: All comments and edits may be updated prior to billing. After the billing cycle, the comments will be read only. Supervisors may mark the comment billable up to a period of 180 days after the comment has been filed. 9. Click [Save]. Note: Do not click on the PRINT THIS SERVICE NOTE link at the top of the screen until after changes are saved. Reviewing Service Notes Version 3.1 6-10

Demonstration 6-1: Review Service Notes (continued) Steps Continued: Tips: If the Supervisor is entering the comment, the supervisory edit field is not mandatory. In situations where the Supervisor modifies the content in the Service Note, a Supervisory edit must be completed identifying the change. Supervisors may edit the comment directly if within the billing cycle timeframe. Reviewing Service Notes Version 3.1 6-11

Demonstration 6-2: Advanced Search for Service Notes This demonstration will review the process of searching for service notes using advanced search techniques in HCSIS. To become familiar with this process, use the following steps. Menu Path: SC SC Service Notes SC Service Notes Search Steps: 1. Using the menu path, navigate to the Service Notes Search Criteria screen in HCSIS. 2. Click [Advanced Search]. Reviewing Service Notes Version 3.1 6-12

Demonstration 6-2: Advanced Search for Service Notes (continued) Steps Continued: 3. Use any of the following fields to search for service notes: Field Last Name First Name From Contact Date To Contact Date Description Enter the last name of the individual whose service notes you want to review. The search will not work if the name is not spelled correctly. Enter the first name of the individual whose service notes you want to review. The search will not work if the name is not spelled correctly. Narrows the search to include only those comments with a time of activity entered by the SC on or after the date entered in this field. A suggested date will default in this field. Narrows the search to include only those comments with a time of activity entered by the SC on or before the date entered in this field. A suggested date will default in this field. Continued Tip: Use as many search fields as possible. If a list of Service Notes is needed, use the Service Note extract. Reviewing Service Notes Version 3.1 6-13

Demonstration 6-2: Advanced Search for Service Notes (continued) Steps Continued: Field From Entry Date To Entry Date Identifier Type Identifier Comment Author Last Name Comment Author First Name Category Subcategory Caseload Service Type Sort By Description Narrows the search to include only those comments created on or after the date entered in this field. A suggested date will default in this field. Narrows the search to include only those comments created on or before the date entered in this field. A suggested date will default in this field. To search by an individual s social security number, select SSN from the drop-down list. To search by business service unit, select BSU# from the dropdown list. Note: If this field is used, the Identifier field will require an entry. Enter the social security number or business service unit number, as indicated in the Identifier Type field. Enter the last name of the author of the service note to identify the notes made by a particular person. Enter the first name of the author of the service note to identify the notes made by a particular person. Narrows the search to include only the service notes in a certain category. A category is the activity described in the service note. Narrows the search to include only the service notes in a certain subcategory. A subcategory is the service/support described in the service note. Narrows the search to a specific SC s caseload. Narrows the search to include only the service notes with a certain service type. Sorts the Service Notes Search results in descending order by one of three criteria: Consumer Name Date of Contact Date of Entry Continued Reviewing Service Notes Version 3.1 6-14

Demonstration 6-2: Advanced Search for Service Notes (continued) Steps Continued: Field View Description Narrows the search to show only a certain type of service note. Choose one of the following view types: TSM Activity only displays service notes for individuals who are MA eligible Follow-up only displays service notes flagged for a follow-up with the individual Summary displays service notes in a summary format Text displays the text in the service notes Note: This is a required field. 4. Click [Search]. 5. Refer to the prior demonstration in this lesson to edit the service notes that appear from your advanced search. Reviewing Service Notes Version 3.1 6-15

Exercise 6-1: Reviewing Service Notes You want to review the service notes made by one of the SCs you supervise. Make supervisory edits to the service notes. Use the data sheet handed out in class to perform these tasks. Reviewing Service Notes Version 3.1 6-16

Reviewing Service Notes Review 1. Who can make supervisory edits to service notes? 2. What are some of the ways you can search for service notes? Reviewing Service Notes Version 3.1 6-17

Answers to Reviewing Service Notes Review 1. Who can make supervisory edits to service notes? Only SC Supervisors and SC Unit Managers can make supervisory edits to service notes. The County SC Oversight role has read only access to the existing service notes, but they can add their own service notes. 2. What are some of the ways you can search for service notes? Service notes may be searched by individual, SC, comment categorizations, dates, and categories. Reviewing Service Notes Version 3.1 6-18