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Create a Progress Note (AOA/CC/HC)

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Create an AOA-CC-HC Progress Note
Enter Your Notes

Create an AOA-CC-HC Progress Note

NOTE: Follow your discipline specific documentation standards, as a Progress Note is a legal document.

1. From the Shortcuts Application select Casenotes or click the casenotes.png button in the navigation bar. This will take you to the Casenotes Application. From the Casenotes Application, click the create_a_new_case_note.png button.

2. If you are a member of more than one team, an Owner Key lookup will appear. Select the Team providing the service.

3. The Case note type lookup then appears:

case_note_lookup_aoa.png

  • Select PROGRESS NOTE
  • OR PROGRESS NOTE – [VARIATION] (e.g. PROGRESS NOTE – PALLIATIVE), follow your program’s instructions.

4. Click AcceptChanges.png

5. The Referral lookup then appears:

referral_lookup.png

  • Select your discipline-specific referral.
  • If there is only one referral open, it will auto populate to that referral.

6. The Casenote document then appears with a header section:

header.png

7. Enter the following fields:

  • Date: Today’s date defaults in. If this is incorrect, enter correct date; PARIS date format is dd/mm/yyyy
  • Time: Default is current time. Guidelines state default time should be left as is and corrected times entered into body of Case Note
  • Duration and Location are not used
  • Staff Team: Defaults to your team
  • Staff Member: Defaults to the logged on user’s name.
  • Origin: Defaults in to origin of casenote
  • Type: Becomes read-only. If you select the wrong Type click Cancel and start again
  • Reason: Click the MagnifyingGlass2__4_.gifor press F4 to activate the Case note reason lookup:

case_note_reason_lookup.png

Select the appropriate reason from the picklist (click “Include team restricted codes” if you do not see one of the case note reasons below. Ensure you only use the casenote reasons that are approved by your program).

  • CASE CONFERENCE (code = CC)
  • DISCHARGE NOTE (code = MHDIS)
  • ENTERED IN ERROR (code = EIE)
  • FIRST CONTACT NOTE (code = FCN)
  • GP/NP CARE CONFERENCE (code = GPCC)
  • ONGOING CARE (code = OC)

8. In the Referral Link Information section, confirm that the current progress note is linked to the correct referral. If the incorrect referral was selected, Tick the box 'Click to Update Associated Referral' and select your discipline-specific referral.

9. In the Today's Contact Information for MRR section, for contacts #1, 2, 3, and 4,

  • Select Contact Type (e.g. Face to Face, Video, Phone, Email or Text)
  • Select Service Delivery Setting (e.g. Home or Ambulatory Home Care)
  • Enter Duration (hr and min)
  • Select Time of Service (e.g. Day – client care started between 0800 and 1629; Evening – client care started at 1630 or after).

aoc.png

10.  In the Vital Signs section users can record any vital signs information gathered during their visit by clicking the Insert a Row button.

vital stats.png

11. In the Home Health/End of Life Client Risk Category section ensure the client has an entry as all home health clients require a completed Home Health/ End of Life Client Risk Categorization to be completed.

This section also has a Guidance note button which if clicked opens up a window that contains a the HH/EOL Click Risk Categorization Table as well as a link to the Home Health/End of Life Client Risk Categorization SOP.

risk category.png


12. In the Care Plan Interventions section users can update, close, or enter in error their Interprofessional Care Plan (ICP) entries. All active ICP entries will appear in this section and users can review the details within the Care Plan Interventions grid as well as view the intervention details in full by selecting one of those entries which will then display that information in the Intervention Details View (Read Only) section right below.
 

care plan intervention.png

For more information regarding how to update, close or enter in error ICP entries please click this link [VCH] Interprofessional Care Plan Guide and review the How to Modify Care Plan Interventions, How to End a Interprofessional Care Plan, or How to Enter in Error a Interprofessional Care plan section.
 

Enter Your Notes

1. Click inside the Document box and type your notes. In the document section, focus charting will be used.

document.png

2. Follow your discipline-specific Casenote format.

3. In the Document section, enter narrative information. This should consist of the following in this order:

  • Time and Type of contact (e.g. 1000 Home Visit or Phone Call) AND if required, enter “Late Entry for <DATE>.” 
    NOTE: for late entry, ensure you change the Date in the Header (top of the page, see step 6 screen shot above) to reflect the date of service. Your signature stamp will reflect the date/time of documentation.
  • New Line: Focus of charting bolded (i.e. Client Need heading or SOAP title – follow your discipline specific-guidelines)
  • New Line: Narrative information
  • A new line will be started for each new issue and a space should be left between issues.
  • New Line: "Plan" and bold, enter narrative notes
  • New Line: End with Date/Time/Signature Stamp (Ctrl-T)

document_2.png

4. Press F12 to Save.