Description: In this topic, the user will learn how to complete care notes with goal tracking from the employee profile in the mobile app. This topic will also review how to view completed care notes, view and edit pending care notes, and how to publish care notes during the shift and after clocking out of the shift. The mobile app allows the employee to track a client’s plan of care and document progress toward goals. A care note is automatically created by DCI when a punch is created for a client with active goals for that service code.

Role Required: Employee with a client who has Care Management enabled

Permission Required: N/A

Enter a Care Note and Goal Tracking

  1. Log in to the mobile app with the employee (base user) profile

    1. An active shift must be in progress (blue Continue to Clock Out button will be displayed at the top of the dashboard)

    2. The Client Details button will be displayed below the Continue to Clock Out button if Care Management is enabled for the client. It appears on the dashboard when the Clock In has been confirmed.

      1. Click the Client Details button, then the Plan of Care button to view read-only information relating to goals, tasks, and met and not met conditions.

    3. The Care Notes field displays care notes from the current shift only

  2. Click Action, located in the upper-right corner of the screen

  3. Click Goal Tracking to add a care note and open the goal tracking screen

    1. Goals can be tracked at any time throughout the shift, at the end of the shift before publishing care note or after the shift if not published at clock out

    2. Please note: Add Note or Add Attachment are additional available options after clicking Action. These options do not record or report under Care Management. Do not use these functions to add a Care Note. These options are also available on the Confirm Clock Out screen and are used to add a note or attachment to the client profile.

  4. Click Goal

    1. A popup with a list of the available goals will display. Select the Goal. A checkmark will display next to the selected goal.

    2. Click Ok

  5. Click Task

    1. A popup with a list of the available tasks will display. Select the Task. A checkmark will display next to the selected task.

    2. Click Ok

  6. Click Result

    1. A popup with a list of the available results will display. Select the Result. A checkmark will display next to the selected result.

    2. Click Ok

  7. The Add Notes for Result field is optional

  8. Questions may be listed based on the task selected

    1. To result (answer) the question, click the down arrow under the question to display a popup with a list of available answers

    2. Select the Answer. A checkmark will display next to the selected answer.

    3. Click Ok

  9. Optionally, click Attachments to add a picture directly to the care note.

  10. Click the Save button

Multiple goals may be tracked during a shift with a client in the mobile app only. Repeat steps 2-10 to track another goal.

Care Notes at Clock Out 

  1. Log in with the employee (base user) profile in the mobile app

  2. Click the blue Continue to Clock Out button. The system performs a check to see if there are any required tasks that have not yet been resulted and checks the Require Care Notes setting on the service code. The require care notes setting is determined by service code per organization.

    1. If there are tasks that have not yet been resulted and the Require Care Notes setting on the service code is Yes, a pop-up alert states "Care notes are required for this punch. Please enter results to continue clocking out."

      1. Click Confirm to acknowledge. The app redirects the user to the goal tracking screen for completion.

      2. Select a goal, task, and result.

      3. Click the blue Save button. This action must be repeated for each required goal and task.

      4. The app then directs the user to the EVV clock out screen or the final clock out screen (if EVV is not being collected)

      5. Select an EVV Location if applicable

      6. Add optional notes and/or attachments for the punch

      7. Select canned statement(s)/task(s) if applicable

      8. Click the blue Publish Care Notes and Clock Out button

        1. Please note: Published care notes cannot be edited

    2. If there are no tasks that need to be resulted, or there are no required tasks, the app directs the user to the EVV clock out screen or the final clock out screen (if EVV is not being collected).

      1. Select an EVV Location if applicable

      2. Add optional notes and/or attachments for the punch

      3. Select canned statement(s)/task(s) if applicable

      4. The app displays one or both blue buttons listed below. Select one:

        1. Publish Care Notes and Clock Out

          1. Please note: Published care notes cannot be edited

          2. If the require care notes setting is enabled for your organization, this will be the only option available.

        2. Clock Out without publishing Care Notes

          1. Care Notes do not need to be published at clock out or to complete a punch. The system tracks whether or not care notes are provided and published.

  3. Click Confirm

View, Edit, and Publish Care Notes after Clock Out

  1. Log in with the employee (base user) profile in the mobile app

  2. Select the main menu icon (three horizontal lines) in the upper-left corner

  3. Select Care Management from the submenu

  4. The Care Management screen will open displaying three widgets:

    1. Active Clients - Select an Active Client from the list to view client details, plan of care, and punch entries details.

    2. Pending Care Notes - Select a Pending Care Note from the list to view the punch details, view client details including the plan of care, view and edit pending care notes, and add goals, care notes, notes, and attachments.

    3. Published Care Notes - Select a Published Care Note from the list to view the punch and client details, care notes, notes, and attachments.

  5. Select a Pending Care Note to edit and publish

    1. To edit existing unpublished care notes, select the goal listed in the Care Notes widget.

      1. Complete necessary edits on the Goal Tracking screen

      2. Click Save

      3. OR click Delete to delete the care note and remove the goal and care note from the punch entry

    2. Add a goal and care note by clicking Action, located in the upper-right corner of the screen.

      1. Click Goal Tracking to add a care note and open the goal tracking screen

      2. Select the goal, task, and result.

      3. Optionally, add notes in the Add Notes for Result field.

      4. Result (answer) questions that may be listed and associated with the task. Click the down arrow under the question to display a popup with a list of available answers.

      5. Optionally, click Attachments to add a picture directly to the care note.

      6. Click Save

  6. Click the Publish button to publish the care note

    1. Please note: Care Notes cannot be edited once published