FILTER | REVIEW SERVICE NOTE/ASSESSMENT | VIEW INTEGRATED ASSESSMENT | NEXT | NAVIGATE TO | ORANGE REVIEW SECTION LINK | ADD COMMENT | SPELL CHECK | EDIT COMMENT | DELETE COMMENT | CLOSE COMMENTS | MARK SERVICE NOTE INCOMPLETE AND SEND MESSAGE TO REVIEW SERVICE NOTE/ASSESSMENT | ASSOCIATE PROCESS FOR QA REVIEW | QA AND RESPONSE EXIST | SECTION REVIEW HISTORY | PINK REVIEW SECTION LINK | QA DONE LINK | APPROVE SERVICE NOTES | QA DONE CHECK BOX | UPDATE DIAGNOSES CODES | APPLY CO-SIGN SIGNATURE | REMOVE CO-SIGN SIGNATURE | GENERATE INTERIM ORDER | REPORTS | SUBMENUS | QUIZ
QA Review provides you with a listing of all Service Notes that are part of your quality assurance (QA) review. This listing provides you with all Service Notes that are in the approved, complete, incomplete and voided status. You will also be able to complete your QA review, mark the service note incomplete and send an internal message to the clinician who created the note using this new option. Use the following path to access/use this menu option: Processes menu > QA Review option
Select the drop down <btn> Select Agency ▾ <btn> to the right of Agency
Select the drop down <btn> All ▾ <btn> to the right of Payer Reporting Group.
Select the drop down <btn> All ▾ <btn> to the right of Team
Change the Date Range as necessary to review a listing of Service Notes you want to work with (currently defaults to 2 weeks prior to current day) and select the "Search" button.
You can filter by selecting the drop down <btn> All ▾ <btn> under Type
You can filter by selecting the drop down <btn> All ▾ <btn> under Performed By...
You can filter by selecting the drop down <btn> All ▾ <btn> under Service...
You can filter by selecting the drop down <btn> All ▾ <btn> under Note Status...
You can filter by the following statuses
and you can filter by selecting the drop down <btn> All ▾ <btn> under QA status
You can filter these by the following statuses
To review a service note, the service must be in a completed or approved status. Click on the drop down <icon-action>xxx<icon-action> to the right of the service note
Choose <icon-dataok>xxx<icon-dataok> <udl-orange>Review Service Note/Assessment<udl-orange>
<icon-magnify>xxx<icon-magnify> <udl-orange>View Integrated Assessment<udl-orange> allows you to view a PDF version of the service note.
You can navigate throughout the assessment using either <btnw> Next <btnw> OR
When reviewing the service note, you can navigate through the service note just like you would if you were actually doing the visit by clicking on the drop down <btn> Header and Supplies ▾ <btn> to the right of Navigate to. Choose the section that you want to review from the drop down.
Each section has a <udl-orange>Review Section<udl-orange> link to the right of the title of the section. An orange link indicates that the section has no review comments added. Click on this link to add comments for correction.
The Section Review History box opens. Click on <btn> Add Comment <btn> to add your comment.
The add comment box opens.
Add your comment and click <btnw> Save <btnw> when you are finished.
You can also “Spell Check” <icon-spellcheck>xxx<icon-spellcheck> your comments.
Once you save, you can add another comment…
Edit <icon-greenpencil>xxx<icon-greenpencil> the current comment
Or delete <icon-trashcan>xxx<icon-trashcan> the comment.
You will be asked if you are sure you want to delete your comment. If so, click “OK”.
Click <btnw> Close <btnw> when you are finished with your comments
When you have reviewed each section, click on <udl-orange>Mark Service Note Incomplete and Send Message To Review Service Note/Assessment<udl-orange>. This will mark the assessment incomplete and also send a message to the associate that they need to review the assessment.
Click <btnw> Close <btnw> when you are finished.</btnw></btnw>
This will bring you back to the QA Review Process screen. You will now see that the status of the note changed to “QA and Response Exist”.
See below for this process.
When your service note is back in a completed status, the service note will now appear in the QA Review Process under the status of <btn> QA and Response Exists ▾ <btn>.
To review the responses, click on the drop down to the right of the service note and choose <icon-dataok>xxx<icon-dataok> <udl-orange>Review Service Note/Assessment<udl-orange> again just like you did initially.
Click on <udl-orange>Section Review History<udl-orange>
This will open up the Section Review History where you can view at a glance any comments you made and the responses per the associate. Click on the link to go to the section you reviewed.
The <udl-pink>Review Section<udl-pink> link will now be pink. Review the changes made in the section and click on the “Review Section” Link if you are not satisfied with the changes and need to send it back to the associate.
Here you can add another comment and send back for review. Each comment you add, must have a response from the associate before the note can be completed.
Once you have completed reviewing all section in the Section Review History, click <btnw> Close <btnw>
If you are satisfied with the corrections, click on the <udl-orange>QA Done<udl-orange> link at the top of the service note
You will be prompted to add a QA Done comment. Click <btn> Add Comment <btn>
Enter a comment regarding the review and click <btnw> Save <btnw>
You will be returned to the QA Review Process where you will notice the note is no longer here if you chose ”QA Done’.
If your process is to approve service notes for associates, you can also do this in the QA Review Process by clicking on the service notes you need to approve and then choosing <udl-orange>Change Status to QA Done and/or Approved<udl-orange>.
If your process is not to review every note, then you may want to mark the note as QA Done so that it no longer shows up in the QA Review Process. To do so, click on the service notes that you do not want to review and choose <udl-orange>Change Status to QA Done and/or Approved<udl-orange>.
You will be prompted to <btn> Add Comment <btn> .
Add your comment and click <btnw> Save <btnw> when finished. All the notes that you just checked off will now show a status of “QA Done’.
You can also update diagnoses codes for service notes that include them. Click on the drop down to the right of the service note and choose <icon-editpencil>xxx<icon-editpencil> <udl-orange>Update Diagnosis Codes<udl-orange>.
Make the necessary changes. You can also change the sort order by changing the number to the right of the diagnosis code. Click <btnw> Save <btnw> when finished.
If the service notes are in an approved or completed status, you can add a Co-Signature by clicking on the drop down to the right of the service note and choosing “Apply Co-Sign Signature”. This could include RN’s signing LPN Service Notes as well as Therapists co-signing Therapy Assistant Service Notes. This feature/function appears on the Patient Encounter Service Notes tab and is only available for Service Notes that do not contain OASIS information. Hover over the “View actions” <icon-action>xxx<icon-action> dropdown arrow for the Service Note you want to co-sign > Select the <icon-editpencil>xxx<icon-editpencil> <udl-orange>Apply Co-Sign Signature<udl-orange> link from to pop-up list
Click <btn> Accept <btn> to apply your signature</btn></btn>
Additional signature section prints below the signature of the clinician that completed the Service Note.
Example of Service Note with both Signatures
If for some reason, you need to remove the Co-Signature, click on the drop down <icon-action>xxx<icon-action> to the right of the service note and choose <icon-trashcan>xxx<icon-trashcan> <udl-orange>Remove Co-Sign Signature”<udl-orange>. Just remember, if you mark a service note incomplete, it automatically removes the co-signature.
In some situations you such as maybe a Therapy Evaluation or Discharge, you may want to send the service note to the physician for a signature. You can generate an interim order from service notes that are approved as well by clicking on the drop down to the right of the service note and choosing <icon-greenredarrows>xxx<icon-greenredarrows><udl-orange>Generate Interim Order<udl-orange>.
You will be asked if you are sure you want to create an other interim order. Click “OK” to do so.
This will create an other interim order on the Orders tab for you to sign and then you can send the service note to the physician for signature.
You can also run reports on QA/Review and Responses” if you need to after you have set all your parameters, click on <btnw> Search <btnw> and then choose <btnw> Export <btnw>.
<btnw> QA/Review and Response ▾ <btnw> (Spreadsheet)
Only available to Careficient Employees.
Only available to Careficient Employees.