On December 5th, 2023, the new version of the SLP Progress Note casenote form, SLP assessment forms, and reports were introduced.
To create a SLP progress note in the Casenotes tile:
1. Go to the Shortcuts Tile and click on the Casenotes application.
2. In the navigation bar, click on .
3. If you are a member of more than one PARIS team, an Owner Key lookup will appear. Select the appropriate team providing the service. If you are a member of only one team, PARIS automatically selects the team for you and you can skip this step.
4. The Case note type lookup appears. Select PROGRESS NOTE-SLP V2 (Code = PNSLPV2).
5. Click on Accept Changes.
6. The Progress Note-SLP V2 casenote appears. Enter the appropriate casenote Reason in the Header section at the top of the page. For the purposes of statistics collection, it is important to only use the casenote reasons outlined in the regional SLP guidelines.
7. If the client had multiple open referrals to your team and the wrong referral was selected, you can change the referral by clicking on the ‘Click tick box to Update Associated Referral’ checkbox in the Referral Casenote Link section.
8. If appropriate, select any Clinical Care Plan goals to link to the casenote by clicking on the ‘Link casenote to goal(s)’ button. In the Progress Note-SLP V2 form, the character limit that will display in the preview Details box is up to 200 characters on the Link to goal(s) screen.
If there are no CCP goals or if the casenote is not related to a specific goal, check off the ‘No care plan link’ tickbox.
9. The SLP Client Status section is a new grid section that will be used to record the client status, client score and status review date.
Each documented status will be displayed and updated automatically in both the SLP progress note V2 and SLP assessment V4 regardless of where the status information was originally recorded. This will allow staff to enter a new status and to view all historic statuses per client in one place, without toggling to different SLP progress notes and assessments.
This table contains general information on when to record/update the status. If the status is accurate you do not need to add/update each time you log a progress note. For more details, please refer to VCH SLP PARIS documentation guidelines or consult with your clinical lead.
A client can only have one active status. To add a new status:
1. Click on Insert a row. The entry form will appear.
2. Select Client status. If applicable, enter Client Score (accepts a number between 0.00-20.00) and/or Status review date (dd/mm/yyyy). Please refer to VCH SLP PARIS documentation guidelines or consult your clinical lead for further information about determining Client Score and Status review date.
3. Click Accept Changes.
4. Click Save. The active status will be seen at the top of the grid section.
When a new status is entered, the system will end date the previous status. It will appear under the Status End Date (Auto Generated) column in the grid. In this example, the current active status DISCHARGE is seen at the top of the grid section. The status end dates were inserted automatically by the system.
If a partial correction is required (e.g., Client Status, Client Score or Status Review date), click Modify row to tick the entered in error checkbox, click Accept changes and Insert a row to record a new row.
On the PH-SLP Caseload Report V3, client status, client score and status review date will be displayed. The current status will be used to group clients on the report.
10. If appropriate, enter SLP activities for the contact/visit.
11. This is a new section that allows for the uploading of PDF files related to the clients from the Home Directory). Examples include the Child Information form and the Consent form for sharing information. Please consult with your clinical lead to learn more about the documents that will be uploaded in this section by your program. Each uploaded document will be displayed in both SLP progress notes and SLP assessments regardless of where the document was originally uploaded. This will allow staff to upload a document and to view all historic documents in one location, without toggling to different SLP progress notes and SLP assessments.
The scanned pdf files should be:
- Maximum file size: 2 MB
- File name: Please use the following naming convention: date, description of the uploaded document, client initials (e.g. 2023-11-23_CONSENT_FORM_YK).
To upload a document:
1. Insert a Row
2. Click Attach file
3. Select the file in your H: Drive. Click Open
4. Enter the Document date.
5. Select the Document type from the pick list.
6. Click Accept Changes and Save.
Once it is recorded, a grid row will be created. In the grid header, the system inserts Recorded By, Form Type and Team Name. On the entry screen, the system inserts Recorded by, Recorded on and Recorded at. Click on View file to view the PDF file that was uploaded.
To record the grid as entered in error (e.g., wrong client or wrong document):
1. Click Modify row
2. Tick on the Enter in error checkbox at the bottom.
3. Click Accept Changes and Save.
The row is now marked as entered in error in the grid. Although the grid row will not be deleted and the file name will be still seen, the pdf file is deleted from the system and no longer viewable. The View file menu is now disabled.
12. If applicable, enter any Next Planned Contact details in the Next Planned Contact section. These fields can also be left blank. Currently, the SLP program isn’t using the section. Please follow up with the regional SLP guidelines.
13. Enter encounter notes in the Document free-text section, as needed. Please refer to your programs documentation guidelines or consult your clinical lead for further direction on what is included in this section.
14, When documentation is complete, click on in the bottom-right hand corner to save the casenote.
Please note the Casenote application will display casenotes entered via the Assessment tile (autogenerated in Casenotes Tile) as well as those manually entered directly into the Casenote tile. Please see the summary below of the key differences between the manually created SLP progress notes from the Casenotes tile and the automated SLP progress notes that are generated from within the SLP assessment form V4.