How to Document Additional Services

Procedures not covered by the situations described above, and which require documentation, will instead be entered using the Service Note feature. This allows you to record both a service and its documentation in one area. This includes both clinical and non-clinical documentable services. 

  1. With an active client selected, click the Search icon.
  2. Type ‘Service Note’ into the search bar.
  3. Click to select Service Note (Client). The Service Note page opens.
  1. Enter Service information.
    1. Select the Program from the dropdown. Based on these choices, options for Procedure and Location will populate. Select the Procedure and Location.
    2. Complete the start time and date.
    3. Select an Attending and Referral option, if applicable.
    4. The Status field defaults to Show. This will immediately initialize the Note tab. If the Service is in the future, select Scheduled instead.
    5. Complete other fields as appropriate.
  2. Click the Note tab.
  1. Complete the note tab according to clinical and organizational workflows. For Inpatient/Residential Psychiatric Notes, see How to Complete the Psychiatric Evaluation.
  2. Complete the Billing Diagnosis and Warnings tab, if necessary.
  1. Click Save.
  2. Click the Sign button to sign the document according to the steps outlined in How to Sign a Document.