• This field is used to document who received the services being documented.
• If the recipient was a group of clients, select Client.
Nurses Notes
This progress note is used by Nurses.
Before you start
- The user must have the CMBHS role of Nurse to use this Progress Note type.
- CAUTION: If you have made a serious documentation error in CMBHS that has or may result in the breach of a client’s rights to privacy, report the event to your supervisor, your Local CMBHS Security Administrator or other person designated by your agency and contact the CMBHS Help Desk at 1-866-806-7806.
How to Access Nurses Progress Notes
• From the Client Services Toolbar on the left side of your screen, Hover on Service Documentation, and then CLICK on Progress Notes.
• After the Progress Note opens, go to the first data field, Progress Note Type.
• CLICK on the arrow symbol in the blue box to open the drop down box menu.
• Select Nursing.
• Complete the standard information data fields and then those fields specialized for Nurses.
• Select the Document Status for the note and CLICK on Save.
Progress Note Type (Required)
• Progress Note types are:
• Counseling - Documentation about delivery of counseling and other therapeutic services and the client’s response. This note type is used by mental health and substance abuse services providers.
• Case Management - Documentation about delivery of case management services and the client’s response to services. Used by mental health and substance abuse services.
• Nursing- Used by nurses to enter assessments, diagnoses, observations, and recommendations. Nurses may also document information related to the medication. This note type is used by mental health and substance abuse services providers. CMBHS will verify the credentials of the user to ensure that they have the proper credentials.
• Physician - Used by physicians to enter assessments, diagnoses, observations, justifications and recommendations. This note type is used by physicians providing mental health and substance abuse services. CMBHS will verify the credentials of the user to ensure that they have the proper credentials.
• Detoxification Monitoring - Used only by substance abuse detoxification programs to document a services and the client’s response.
• Other - Used to document clinically relevant events that for some reason do not fit into one of the other progress note types. If you select Other as the Progress Note Type, a field labeled Other Progress Note Type will display. CLICK in the box and begin TYPING information.
• Medication Services - Used by Licensed Medication Specialists to document the provision of medication services. CMBHS will verify the credentials of the user to ensure that they have the proper credentials.
• HEI Case Management Notes - Used by HEI services case managers to document case manager activities, client response and services accessed.
• Select Nursing.
Performed By (Required)
• This field is used to document the name of the staff that provided the service to the client.
• The default is your name - the staff creating the Progress Note. If you are documenting services that you provided to the client, your name should be displayed.
• If you are documenting a progress note about services provided by another staff, then you must make a change to this field. Remove your name by selecting the name of the correct staff from the drop down list.
Contact Type (Required)
• Use this field to document the type of contact you had with the client.
• The answer choices are:
- Face to Face – The clinician provided services to the client in person.
- Telehealth - A service provided by a physician (or other health care provider within the scope of their license or certification) for the purpose of diagnosis, consultation, treatment, or transfer of data, using interactive audio or video, still-image capture, or any other technology that “facilitates access to health care services or medical specialty expertise”. CLICK HERE for more information on Telehealth Services. (link under construction)
- Telephone – The clinician and recipient have contact by phone.
Recipient Type (Required)
• This field is used to document who received the services being documented.
• If the recipient was a group of clients, select Client.
Service Location (Required)
• This field is used to document the location where the service was provided to the client.
Service Date (Required)
• In this field, the user should document the date that the service was provided to the client.
• Enter the date in the text box by entering 8 numbers (mmddyyyy) and CMBHS will put them on the correct date format (mm/dd/yyyy) or you may enter the numbers and slash marks yourself (mm/dd/yyyy).
Start Time (Required)
• This is the place to document the time that service delivery to the client began.
• TYPE the time into the text box, entering the 4 numbers (hhmm) of the time and CMBHS will put them in the correct time format (hh:mm) or you may enter hh:mm.
End Time (Required)
• This is the time the services to the client stopped.
• Put the time in the text box by entering 4 numbers (hhmm) and CMBHS will put them in the correct time format (hh:mm) or you TYPE in enter hh:mm.
NOTE: The Begin and End time you document for a service should reflect the amount of time you spent with a client; preparation and documentation time may not be included.
Duration (Required)
• This field will fill in automatically using the Start Time and End Time information you entered in the fields above.
• Duration is displayed in minutes.
If the Unit Type = Hour, then Unit = Duration/60 Minutes (round-down to the closest 15 minutes. For example: Duration = 75 then 75/60 = 1 Unit
Show only open services
• This is an optional filter tool that can make documentation easier for the user. This is not a data entry field.
• Check this box if you want to limit the list of services that will display in the Service Type drop-down list to only those services that are currently open for this client. This means the services for which the client has a current begin service at this location.
• If you do not check the “Show only open services” box, the list of services that will display will include all services offered at your location.
Service Type (Required)
• Use this field to document the type of service the client received.
• The answer choices that display are determined by the services provided at your location and services authorized for this client and whether you have checked the “Show only open services”.
Service Intensity (Required for mental health services only)
• Displays for MH service locations only. This field is used to document the intensity of the client’s need for services.
• Select the appropriate answer from the drop down menu.
• The answer choices are:
• Urgent – The client is in crisis and in need of Mental Health Services (or other necessary interventions) because of they are potentially at risk of serious deterioration, but they do not pose a risk of harm to self or others.
• Emergent - The client is in crisis and in need of Mental Health Services (or other necessary interventions) to address their immediate needs to assure the safety of the client and others who may be placed at risk by their behaviors.
• Routine – The client is not in crisis but does need Mental Health Services.
Service Description (Required)
• The service description list filters based on the service type selected, the business entity type and age type of client.
Service Units (Required)
• If the service units entered in a Progress Note are greater than the approved units in service authorization, CMBHS will display the message "More units have been entered than are authorized". CMBHS will not prevent you from entering the note; it simply notifies you of the authorization status. You will be allowed to Save the record.
• Do not enter Billing Units that are one day or greater. They will be filtered out by CMBHS if they are entered here. Enter Billing Units that are one day or greater in the Day-Rate Attendance Record.
CLICK HERE for information on the Day-Rate Attendance Record. (Under construction)
Billing Unit (Required)
• This information will be pre-filled according to the Service Description you selected and other information in CMBHS about the service location.
• This field is view only and can not be changed by the user.
• If this field displays information that does not appear correct to you, please contact your local CMBHS Administrator about your concern.
Billable (Required)
• This field is used to document whether the note represents a Billable Service or not.
• Select Yes if the service is billable; select No if the service is not billable.
• CLICK in the Yes or No circle to answer. A green dot will appear in the circle you have selected.
Topic Addressed (Required)
• Document the topic that was discussed with the client(s) (and/or service recipients) into the text box.
Session Narrative (Required)
• This field is used to document the client’s response to services, information that will assist other clinicians/providers in delivering the safest most effective services to the client and/or other information that must be documented as required by law or contract.
• Your organization and others may require that you document the narrative part of your progress note using a certain format. CMBHS does not require a specific format and allows you to enter text using any format.
• 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 it and begin typing.
Document Status (Required)
• Select a Document Status from the drop down list before saving your documentation.
• The statuses available to you will depend on your role(s).
• The Progress Note Document Status choices are: Closed Complete; Closed Incomplete; Draft and Ready for Review.
Comments (Not required)
• You may enter additional information or comments in this box if needed.
• This information 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.
• To enter comments, CLICK in the Comments text box and begin typing.
What’s Next?
After selecting the Documents Status for the Nurses Progress Note, CLICK on the Save button. CMBHS will save your note to the client’s health record in the DSHS CMBHS database.
If you select Closed Complete or Ready for Review, CMBHS will conduct an edit check to ensure that all the required fields have been filled in properly before it saves your Nurses Progress Note to CMBHS. CMBHS does not conduct an edit check if you select the Draft or Closed Incomplete document status.
Successfully Saved Message
If a Successfully Saved message appears after you CLICK on the SAVE button, your documentation is complete, has passed the data check and is saved to the client’s record in CMBHS.
1. CLICK on the OK button to make the Successfully Saved message box disappear. The finished Progress Note will display.
2. CLICK on Close.
Error Message
1. If the CMBHS system detects an error while conducting the edit check, an Error Message will appear to inform you of the problematic field(s).
2. After reading the error message, CLICK on the OK button, and you will be taken to the 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.
3. After you have corrected all the errors, the Successfully Saved message will display. CLICK on the OK box and the Progress Note will close.
How to Edit or Delete a Nurses Note
The process to Edit or Delete a Nurses Progress Note is the same as with other progress notes.
Before You Start
- Your business entity and service location must be authorized to document service delivery information in the client’s record.
- Only the creator of a Progress Note or a person with the role of Clinical Supervisor can edit a Progress Note in Closed Complete status or delete a Progress Note in Draft status.
- You must be at the location where the Progress Note was created to Edit or Delete a Progress Note.
- Always verify that you have the correct client record by checking the client’s name and at least one other identifier at the top of the page before you begin.
How to Edit a Nurses Note
• If you need to make a change to a Nurses Note after it has been placed in Closed Complete status, you must first go to the Client Workspace to locate the note to be changed.
• In the Client Document List, go to the Progress Notes by CLICKING on the Progress Notes Tab. The list of Progress Notes in the client’s record for this Episode of Care will display.
• Find the Note you need to Edit and select it by CLICKING anywhere in the row to highlight it.
• CLICK on the View button and the Progress Note will display.
• Next, CLICK on the Edit button in the upper right hand corner of the page.
• Make the needed changes to data fields of the Progress Note and CLICK on the Save button.
• You will receive a Successfully Saved message or an Error message. If you receive an error message, follow the instructions to make corrections and then CLICK on the Save button again.
How to Delete a Nurses Note
• If you need to Delete a Nurses Note, you must go to the Client Workspace to locate the Progress Note to be deleted.
• In the Client Document List, go to the Document Tabs.
• Select Progress Notes by CLICKING on the Tab. A list of Progress Notes in the client’s record for this Episode of Care will display.
• Find the note you need to Delete and select it by CLICKING anywhere in the row to highlight it.
• CLICK on the View button and the Progress Note will display.
• CLICK on the Edit button in the upper right hand corner of the page. Make the needed changes to data fields and CLICK on the Save button.
• You will receive a Successfully Saved message or an Error message. If you receive an error message, follow the instructions to make corrections and then Save again.
NOTE: A Nurses Note must be in Draft status to be Deleted.
NEXT
CASE MANAGEMENT Notes
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