Page #NTS028

Administrative Notes

ADMINISTRATIVE NOTE FOR MULTIPLE-CLIENTS

An Administrative note is used to document non-clinical events and other information that must be documented in a client’s health record for administrative or legal reasons. Administrative notes do not include information that is clinical in nature – meaning that contain information about the client’s condition, needs, treatment or response.

In CMBHS, Administrative Notes may be documented for a single client or for multiple clients. To use the single-client note function, you must be in the record of the client that you are documenting on. The multi-client function puts the same note in the health record of each client the user selects from a list of active clients at the location.

This is accomplished from the Administrative services toolbar at the top of the page and can be done from anywhere in CMBHS.

The following information is about documenting Administrative Notes for multiple-clients on page NTS028

Documenting Administrative Notes for Multiple Clients

Before You Start

• You must be assigned a role that permits you to document Administrative Notes in CMBHS.
• For more information about the CMBHS roles that have read and write access to this page, CLICK HERE.
• Remember there are 2 different types of Administrative Notes in CMBHS – one to document on a single client and one to document on a group of clients.

 

YOU ARE CURRENTLY IN THE HELP FEATURE FOR DOCUMENTATION OF A MULTI - CLIENT ADMINISTRATIVE NOTE.

 

Business Rules for Multi-client Administrative Notes

• Multiple-client Administrative Notes can be documented from your Clinician Workspace or anywhere else in CMBHS, however, you must be Logged In to the same location as the client’s that you will be documenting on. You must be at their service location so that their names will display for selection to receive the note.
• If the user is documenting on clients being served at multiple service locations, they must access each location and write one note to be placed in the health record of each client at that location.

EXAMPLE ONE

The fire alarm at the East Temple Clinic goes off unexpectedly during clinic hours. Staff and clients evacuate the building without apparent incident. There are 2 programs in the building; the Adult Substance Abuse Outpatient Clinic and the Child and Adolescent Mental Health Services. The clinic secretary, Mary Jones, documents the clients that were in the building and that participated in the drill which went without incident. Mary already has CMBHS open at the Adult Substance Abuse Outpatient Clinic location, so she documents on the Adult clients first. She selects the multi-client administrative note from the Administrative Toolbar at the top of the page, enters the required information, selects the client and saves the note. The exact same note is placed in the record of each client she selected.

Next, Mary goes to the Account Management Tab, also on the Administrative Toolbar at the top of the page and highlights Change Location. She selects the Child and Adolescent Mental Health Services location and then selects multi-client administrative note. She selects the clients that participated in the drill and writes a note which is placed in each of their records.

EXAMPLE TWO

The town of Warrenville must evacuate due to projected flash floods and the Warrenville Methadone Clinic will be closed for at least 2 days. A temporary service location has been set up in Jeffersonville in the basement of a church. The staff of the Warrenville Methadone Clinic contact clients with appointments to inform them of the situation and to inform them of the temporary service location.

The Warrenville Methadone Clinic places an Administrative note using the multi-client note function in the records of all the clients they called except one (1). That client became hysterical on hearing the news and needed multiple interventions by phone before calming down. Staff wrote an administrative note in that client’s record and a progress note describing her reaction as it was of clinical concern.

 

• Administrative notes that are in 'Closed Complete' status cannot be edited.
• You can not make a new version of an Administrative note. If you must make a correction, document a new note with the corrected information.

How To Document an Administrative Note

• To use the multi-client note function, you do not need to be in a client record. You can access this function from your CMBHS Clinician Workspace from the Administrative Services toolbar at the top of every page of CMBHS.
• Complete all the required data fields below.

Administrative Note Data Fields

• Complete all the required fields.
• Set the document status and CLICK ON Save.

Administrative Note Type

• Select a note type from the choices below:

Cancellation by client

• Includes cancellations of appointments by the client that are within the timeframe designated by the provider as acceptable for cancellation.

 

Cancellation by Therapist

• Includes any provider generated reason for appointment cancellation

 

Follow-up

• Documentation related to follow-up

 

No Show

• The client does not show up for an appointment or service and does not give the provider notice

 

OSAR

• Documentation by an OSAR regarding an administrative matter

Projected Discharge Date

• Regarding the client’s Projected Discharge Date)

 

Room Assignment

• Regarding the client's Room Assignment in a residential or inpatient program

 

Staff

• Regarding staff assignments.

 

Telephone calls/Non-case management

• Telephone calls about the client made or received by the provider that are non-case management related

Utilization Management

• Regarding a Utilization Management or Authorization issue

 

Wait list

• Regarding the client’s placement on a Wait list, removal from a Wait list or other wait list related matter

 

Other

• Regarding an administrative matter that is not covered by one of the categories above
  • If you select Other, an additional question will display.
• TYPE IN a description of the note type you are documenting in this field.

Activity Date

Required for mental health and substance abuse services

• Document the date that the event or activity occurred in this field. If there is no specific event or activity use today’s date.
• This field defaults to today’s date.
• If you need to change the date, delete the default date and put in the correct date by entering 8 numbers (mmddyyyy) into the text box and CMBHS will put them on the correct date format (mm/dd/yyyy) or you may enter (mm/dd/yyyy) yourself.

Age Group

• CLICK IN either the Adult or the Child/Adolescent box.

Show only open services

This field is Not Required for mental health or substance abuse services

• This box is a filter tool that makes documentation easier for the CMBHS user.
• CHECK this box if you want to limit the list of services that will display to only those that are currently open for this client.
• If you do not check the “Show only open services” box, the list of services that will display will include all services offered at the client’s location.

Service Type

Not Required for mental health or substance abuse services

• Pick the Service Type that corresponds to the service you are writing about.
• The answer choices are determined by the services provided at your location and any current services that may be authorized for this client.
• If the note you are writing about does not relate to the service type, you may leave this field blank.

Narrative

Required for mental health and substance abuse services

• This field is used to document information that must be documented as required by law, contract or policy.
• CMBHS does not require a specific format, so you may type your information into this field using a format specified by your organization’s policies.
• You are not limited on the number of characters you may enter in this text box.
• To enter text into the text box, CLICK IN the box and begin typing.

Performed By

Required for mental health and substance abuse services

• This field is used to document the name of the person that has organizational responsibility for documenting the information or that witnessed an event.
• This field will be pre-filled with the name of the CMBHS user that is creating the note. Your name should display in this field.
• If you are not the person that has organizational responsibility for documenting the information or witnessed an event, and you are documenting for someone else, select their name from the list. Use the drop-down list to display the names of all the CMBHS users at your location.
• Select the name of the person that performed the service by highlighting and CLICKING ON the correct name. The new name you selected will replace your name.

Document Status

Required for mental health and substance abuse services

• Select a Document Status from the drop down list before saving your documentation.
  • The Progress Note Document Status choices are:
    • Closed Complete
    • Closed Incomplete
    • Draft
    • Ready for Review

Comments

Not required for mental health or substance abuse services

• You may enter comments in this box that relate to the Client Rating fields. Only include information that relates to those fields.
• Your comments will be entered into the client’s health record and will be seen by those that have the authority to view this part of the record. Under some circumstances, this may include the client.
• Always consider the consequences of entering sensitive information such as HIV status.
• To enter comments, CLICK IN the Comments text box and begin typing.

What’s Next?

• After selecting the correct Documents Status, CLICK ON the Save button. CMBHS will save your note to the CMBHS database. Before it saves however, it will conduct an edit check to make sure that all the required fields have been filled in properly.
• If a Successfully Saved message appears, your documentation is complete and saved to the client’s record in CMBHS. CLICK ON the OK button to make the message box disappear.
• The finished Administrative note will display in the client’s health record. Go to the workspace of the client, and CLICK ON the Administrative Note tab or the View All tab to view this note..
• If the CMBHS system detects an error while conducting the edit check after you press the Save button, an Error Message will appear to inform you of the problematic field(s). After reading the error message, CLICK ON the OK button, and you will be taken to the first field that requires correction.
• Correct the error ,then CLICK ON the Save button.
• You will continue receiving error messages until all the problems are corrected. After you have corrected all the errors, the Successfully Saved message will display. CLICK ON the OK box and the Progress Note will close.

NEXT,

CLICK HERE to go to 'CLIENT PAYMENTS'