Service Documentation

Forms are setup with default questions and answer responses. Forms are then linked to service codes or individuals.  As staff are entering services and create documentation, staff will be prompted to answer the questions that are setup on the form.

REQUIRED STEP :  Forms must be set-up (Maintain > Forms) and linked to the consumer (Consumer Master > Assign Forms) for this process to work.

NAVIGATION:  TRANSACTIONS menu > Documentation

  1. Select a consumer by typing the case number in the CASE NUMBER field or use the browse button to view the list of all consumers.  You can also tab to the LAST NAME field and begin typing the last name to select from a list of consumers.  
  2. Click the CREATE NEW DOCUMENT button.
  3. A prompt will appear that states “Would you like to create a new document?”.  Click YES.
  4. In the CREATE NEW DOCUMENT dialog box, select the type of document you want to complete.  Only the forms that have been set-up and assigned to the consumer will appear.  Select the form.  Click NEXT.
  5. In the DATE OF SERVICE field, enter the date the service was provided.
  6. In the FACILITY field, select the facility where the service was provided.
  7. In the SERVICE field, select the service that was provided.
  8. In the LOCATION field, select if the service was provided in the community or at the facility.
  9. Enter the start and end time.
  10.  Click the CREATE button.
  11. The documentation entry screen will appear with the questions setup on the form.  
    1. Staff can select the answers using the drop downs, check boxes, or open text fields.  
  12. After answering each question, click the SAVE AND CONTINUE button.
    1. Questions are required to be answered. You must answer to move to the next question. 
  13. As you complete the documentation, the questions and answers will appear in the grid at the bottom of the screen.  Use the BACK button to edit a previous question or click on the question in the grid.
  14. In the CONSUMER INFORMATION section, you can refer to the consumer’s ISP, daily notes, service notes, or monthly notes if you need to look up any information.
  15. When the documentation is complete, you will see the employee signature appear.  Click the FINISH button to finalize the note.
  16. The Time Based Entry Screen will appear with information populated from the documentation entry.  Review the information and click SAVE to create the billable ticket.

2/2023

NEED MORE HELP?  Submit a ticket to the Help Desk or call (814) 535-7810 or (800) 889-3388