WellSky 11300 Switzer Road

Overland Park, KS 66210 913.307.1000

FAX 913.307.1111 www.wellsky.com

Custom Notes

Behavioral Health & IDD Providers

Custom Notes

Copyright © 1997-2020 WellSky

All rights reserved.

The software contains proprietary information of WellSky; it is provided under a license agreement containing restrictions on use and disclosure and is also protected by copyright law. Reverse engineering of the software is prohibited.

Due to continued product development this information may change without notice. The information and intellectual property contained herein is confidential between WellSky and the consumer and remains the exclusive property of WellSky If you find problems in the documentation, please report them to us in writing. WellSky does not warrant that this document is error-free.

No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or

by any means, electronic, mechanical, photocopying, recording or otherwise without the prior written

permission of WellSky

Microsoft Word, Microsoft Office, Windows®, Windows 2000™, Windows NT™, and Windows XP™ are

trademarks of the Microsoft Corporation.

WellSky

11300 Switzer Road Overland Park, KS 66210

913.307.1000 FAX 913.307.1111 Website: www.wellsky.com

Table of Contents

Table of Contents 1

Custom Notes 3

Service Detail Tab 4

Completing the Service Detail of a Custom Note ................................................. 4

Adding Attachments to a Note 9

Submit Tab 14

How to Add a Co-Facilitator 15

Delete a Saved Custom Note 16

Reviewing a Note 17

Adding an Addendum 20

Printing a Custom Note 22

Resubmitting a Rejected Note 23

Resubmitting a Rejected Note (from Funding Source Billing) 25

Note “Shortcuts” 28

Client Slider ................................................................................................................ 28

Adding Multiple Service Details.............................................................................. 29

Add Service ....................................................................................................... 29

Copy Service ..................................................................................................... 30

Other Editing Tools ................................................................................................... 31

Clear Row .......................................................................................................... 31

Billing Preview .................................................................................................. 31

View History...................................................................................................... 32

Regulation Notice: 33

Electronic Records ................................................................................................... 33

Custom Notes

WellSky is a highly customizable software suite. Entities are able to take advantage of the many templates that already exist while at the same time designing and using company specific documentation. Agencies can also take these custom documents a step further and also make them billable for payment.

Within the WellSky billing components of Custom Notes, users will need to populate the Date of Service (DOS), Service Code, Diagnosis (DX), the Place of Service (POS), the time frame and duration of the time the user spent.

As this process is standard for all Custom Notes, each entity will find that the “Clinical Documentation” tab of a custom note will vary from database to database. The information contained in this documentation will not review the “Clinical Documentation” tab of a custom note (often referred to as “Tab 1”). The purpose of this document is to walk the user through the steps of “Service Detail and Submit Tabs” of a note.

-Below is an example of these Tabs.

“Service Detail Tab”- contains all the details that will be validated for “Billing”. These fields will be discussed later in this document.

“Submit Tab”- allows the user to SUBMIT the note. These fields will be discussed later in this document.

Service Detail Tab

The Service Detail Tab of any custom note will be standard across all databases. This is because WellSky needs a standardized format to allow submission of the note for billing. Users will find that the tab is grouped into 3 sections. The first section will contain information about the client and note creator. The second section, referred to as the “Service Information” will contain the core billing details and is completed by the user. Section three is optional and allows the user to attach any extra documentation to further support the note as a whole.

Users will also see fields that are marked with a red asterisk. These fields must be completed for the note to be saved and/or submitted. Any field without a red asterisk is considered optional and does not have to be completed for a user to save or submit a note.

Note: In the event that a required field is left blank, WellSky will not allow the user to progress to the next step.

Completing the Service Detail of a Custom Note

Since every custom note begins with “Clinical Documentation” (Tab 1) the below steps will take into consideration that Tab 1 has been completed and saved. For questions on how to complete Tab 1 of the entity’s custom note please contact the agency’s “Super User(s)”.

1. The Service Detail tab will appear and the user will see “Section One”. *Some items will have auto populated.

Billing Ticket ID – the unique ID number assigned by WellSky once “Tab 1” is saved. Created On – a time and date stamp that shows when “Save and Continue” was clicked on “Tab 1”. Last Updated On – a time and date stamp that shows the LAST time “Save and Continue” was clicked

on “Tab 1”. Client ID – the unique ID number for the client in WellSky. Full Name – the first and last name of the client. SSN – the social security of the client. MRN – the medical record number of the client. Date of Birth – the client’s birthday.

Clinician – a dropdown list of ALL clinicians in the database. *The dropdown will default to the user that is currently signed in.

Contact Type – a dropdown list of how the note creator interacted with the client (e.g. – face to face, over the phone, etc.)

Site – a dropdown of all sites that the note creator is associated. *If the note creator is assigned to more than one site, the user’s PRIMARY site will display.

2. Confirm the correct name appears in the Clinician dropdown. *This will default to the user logged in.

3. Choose a Contact Type based on how the client and clinician interacted.

4. Choose the site that the service needs to be billed FROM. *This list will vary by user and is based on the sites affiliated in the User Maintenance> Professional section.

5. Once complete, move onto “Section Two”.

6. Add the Date Of Service (DOS) by clicking on the calendar icon and picking a date. *The DOS cannot be later than the current day. WellSky will not display a date later than the current day for this reason.

7. Click the Service field. The user will see a dropdown of available services that can be billed. Pick the

correct service to bill. *Users can scroll through the list -OR- type a code/description.

8. Click the Diagnosis (DX) field. Users will see a dropdown of BILLABLE DIAGNOSES currently in the client’s record and can pick up to four (4) items at this point. The order is important as the first DX to appear will be billed as the primary DX on this note. *”*pri” to the right of a DX will indicate that DX is noted as PRIMARY on the client record.

Note: The “(click to edit)” link. This will allow the user to update details about a DX that is currently on a client record.

Click the link; a pop-up window will appear. Click SELECT to the left of an entry, update any available details and click SAVE. This change will go into effect in real time.

9. Click the Place of Service dropdown to note where the service was performed. *The choices that appear will vary by agency.

10. Enter the Time From and Time To. This can be done in standard or military time. Once these fields are populated, press TAB on the keyboard. This will allow WellSky to compute the duration and that time frame will auto populate. *Some agencies do not require the Time From and Time To field, if there is not a red asterisk on these fields, a Duration is all that is needed.

11. Users will then see a Billing Notes field. This is another optional field and will not affect billing. *EX: This field can be used for further detailing the Place of Service if needed.

Note: Units will always show “0” as the note has not been submitted and/or billed at this stage.

12. Once complete, move onto “Section Three” to attach support documentation -OR- click Save and Continue and proceed to the Submit Tab.

Adding Attachments to a Note

At this point, the note has recorded clinical and billable elements of the service(s) provided. If there is a need to add additional/supplemental documentation to validate the note, users can attach files vs. having to type all the clinical information into the fields of the note.

Starting from the point where the service details of the Note have been completed.

1. Click the +Add Documentation Button.

2. A popup window will appear.

3. The user will have the option to add a new document from the local machine -or- add a document

that is already in the Documentation tab on the client homepage.

a. To upload a document from the local machine.

i. Click Upload Document.

ii. The upload document window will appear.

iii. Pick a Document Type from the drop down list, enter an Effective and Expire Date,

enter the Author’s name of the document being uploaded and click on Select Files.

iv. The “explorer” window will appear. Find the file to attach, highlight it and click

OPEN.

v. WellSky will upload a copy and once complete a confirmation will be displayed.

vi. The uploaded item will appear in the table.

*A check will also appear in the “Select” column to indicate this file will be added to

the note.

vii. Click Attach Selected.

viii. The screen will refresh and the attachment will appear on the note.

*If the wrong item was attached, click the trash can icon to delete the file redo the

above steps.

b. To add a document already in the Documentation tab.

i. Use the search tool to find the document in question.

ii. Once the search finishes, put in a check in the Select column for the item(s) that

need to be attached to the billing ticket.

iii. Click on the Attach Selected button.

iv. The screen will refresh and the attachment will appear on the billing ticket.

4. Click Save and Continue to complete the process and move on to the Submit tab.

Submit Tab

Once the note creator has completed the Clinical Documentation and Service Detail Tabs; the final step will be to sign and submit the note. Based on the user’s setup, the submitted note will either go to the Funding Source Billing screen for review by the finance department -OR- sent to a reviewer.

The user will use the Submit Tab to confirm any attachments are added to the document and as a final verification that all information is complete and comprehensive.

To Submit the completed Note:

1. Click the Submit Note button at the bottom of the screen.

2. The screen will refresh and the note will be locked. The user will not be able to make any more updates to the document.

Note: The Submit Tab has 2 other buttons to the right of the Submit Note option:

Print All – allows the user to print the note in its “native format” (e.g. – MSWord).

View History – allows the user to see a “trail” of the updates and changes that have occurred to the Service Detail items.

How to Add a Co-Facilitator

A Co-Facilitator can be added to a custom note by enabling the “Display Co-Facilitor Dropdown on Note” in the Global Settings.

Note: This setting is not enabled by default so please contact WellSky Support if this option needs to be enabled in the database.

For databases that have this setting enabled, the Co-Facilitator field will appear in the “Enter Service Detail” tab of the custom note. Click the dropdown to choose from a list of users in the entity

• All options on the note will still be based upon the clinician that is logged into WellSky.

• The PIN for the note must be the PIN of the clinician that is signed in and creating the note.

• The Clinician and Co-Facilitator must be different individuals.

• Productivity will be measured for both the Facilitator and Co-Facilitator.

• Enabling the “Display Co-Facilitor Dropdown on Note” Global Setting will add the Co-Facilitator dropdown to the Assessment, Billing Ticket, Custom Note, Dispensing Ticket, Med Note and Progress Note types.

Delete a Saved Custom Note

If a Note was incorrectly created, the option to delete the document is available. Those users with the proper permissions can delete SAVED notes only.

Starting from the point where the Note is opened.

1. Click on Clinical Documentation Tab. *The tab number can vary based on the note.

2. Scroll to the bottom on the page.

3. Click the Delete button.

4. The user will see a confirmation popup. Click OK.

5. The screen will refresh, the Note will be removed from the database and the user will be taken back to

the Service Documentation screen.

Reviewing a Note

If the agency has decided to incorporate note review as a part of the service documentation submission process, the Note may go to a clinical reviewer, manager or team lead for review prior to billing. As a note reviewer, notes waiting for review will be found in the Pending Items section of the Dashboard.

Items awaiting review will have a status of “Ready for Review”. Click on the corresponding Note ID link in the left hand column, titled “Record Type” to open and review the note.

1. The content of the note will be viewable, but NOT editable. Once the content of the Note has been

reviewed, click on the Submit Tab.

2. The reviewer will then make a decision about the Note - Approve or Send Back to Clinician.

a. To APPROVE the Note:

I. Choose the Approve radio button and type in the reviewer’s PIN.

II. Click Submit Note.

III. The note will be sent to the Finance Admin (Funding Source Billing).

b. To SEND BACK TO CLINICIAN (reject for inaccurate information or billing details):

I. Choose the Send Back To Clinician radio button and type the PIN.

II. Click the Add Reviewer Comment link to advise the note creator why the note is being sent

back.

III. The screen will refresh and a “comments” box will appear. Type any details in regard to the

reason for rejection and click Save.

IV. The screen will refresh again and the comment will appear.

V. Click Submit Note to send this note back to the creator.

VI. The screen will refresh and status will update.

The note creator will then be alerted that the note was sent back and it will appear in the clinician’s PENDING ITEMS section of the Dashboard.

At that point the clinician will need to access the note, make the necessary updates and re-submit it for approval again (see the section, Resubmitting a Rejected Note).

Adding an Addendum

Once a note has been electronically signed and billed, it cannot be changed. However, there is a section at the bottom of the note titled, Addendum. This section will allow an update to be added at a later time.

Starting from the point where the user has opened a SUBMITTED Note.

1. Click on the Provide Clinical Documentation tab and scroll to the bottom of the note.

2. Click on Add Addendum.

3. The screen will refresh and there will be two fields to complete: Addendum Notes and PIN.

4. Type in any additional information in the Addendum Notes field.

5. Enter the 4-digit PIN.

6. Click Save. The information will appear in the grid as well as who wrote the addendum and when.

Note: Users can click SELECT to see everything that was written.

Note: All addendums will also appear on the printed version of the note.

Addendums are not editable. If a correction needs to be made to an addendum, another addendum will need to be written.

Printing a Custom Note

In the event a hard or printed copy of a Note is needed; a print option is available. Notes in the status of Billed, Approved or Submitted can be printed.

Starting from the point where the Note is opened.

1. Click on the Submit Tab. *The tab number will vary based on the note’s workflow.

2. At the bottom of the tab, click PRINT ALL.

3. A pop up will appear and ask to Save or Open the document.

4. Choose to Open… and the document will appear in the format chosen.

5. In that chosen format, click the Print button or link.

Resubmitting a Rejected Note

In the event that a note is rejected by a reviewer, that note will come back to the creator to correct. A rejected note will appear in the creator’s PENDING ITEMS section of the Dashboard. These notes will need to be corrected and again submitted for approval. Notes can be sent back for any reason and will be at the discretion of the agency’s policies.

Note: A rejected note is no longer in SUBMITTED status. Once the creator opens a rejected note, it will be “unlocked” and it can be edited.

1. Look in the Pending Items section for any item with the status of, Rejected by Reviewer.

2. Click on the link to open the note.

3. The note will appear on the screen.

4. Click on the Submit tab to read the reason for rejection.

5. Once the details have been read, click on the tab that holds the information to be updated and make

the changes.

6. Click Save and Continue and then click on the Submit tab.

7. Submit the note again.

Note: The PIN will again need to be entered at the bottom of Clinical Information Tab.

The note will again display as “Ready for Review” and the review process will begin again.

Resubmitting a Rejected Note (from Funding Source Billing)

Notes can be reviewed (if the clinician is assigned a reviewer) prior to being sent to the Funding Source Billing submodule. Once a Note is submitted and/or reviewed and submitted, it will go to the Funding Source Billing submodule for the finance administrator to approve. This user does have the option to reject the Note if the correct billing elements were not supplied and send it back to the note creator.

If a Note is rejected in Funding Source Billing, the assessor will see this in the Pending Items on the Dashboard and review the reason for rejection, update the information and then resubmit the ticket for billing.

The Note will show as a status of Saved.

1. Click on the note (hyperlink in the Record Type column)

2. Once the Note is opened, click on the Submit tab. *The number of tabs will vary, however the Submit

tab will always be the last one.

3. Scroll to the bottom and click on View Returned Reason.

4. The screen will refresh and the retuned reason will be displayed.

5. The note creator will need to review the comments and then click the “X” to clear the popup window

from the screen.

6. Go back into the Note and make the necessary corrections.

7. Once the corrections are made, click on the Submit Tab and again SUBMIT the note.

Note: The Note will then go back to a reviewer (if assigned) or to Funding Source Billing to be sent for billing.

Note “Shortcuts”

Throughout this document screen shots are provided to assist in what the user sees while creating, saving and submitting a Note. As most of the details of the note have been explained, there are few areas that might not have gotten attention in the earlier pages, but can be helpful in completing the workflow.

Client Slider

On the side of the screen, users will see the Client Slider. Clicking on this will allow the note creator to easily access pieces of the Client Homepage without closing the note and going into the full client record.

Simply click on the button and a “fly out” will show on the screen.

At this point, client details can be viewed, edited and created in real time. Any changes that occur will be saved the client record.

Note: The client’s name is a hyperlink. Clicking on the name will open the Client Homepage in a new browser tab.

Adding Multiple Service Details

Note creators might save or submit notes that cover more than one day. WellSky has two easy and efficient ways to create a multi-time and/or multi-day note. Users will see links for Add Service and Copy Service (in the top right corner); as well as links for Clear Row and Billing Preview (in the Billing Tools section).

Add Service Adding a Service row allows the user to add another blank Service Detail Box to allow billing for multiple times during the same day.

Complete the first service detail box and then click “Add Service”. A new Service Detail Box will appear and allow the user to input data into the fields.

Note: In the above example there are two different times of the day, different services and different DX’s being billed for the same day.

Copy Service Copying a service row allows the user to duplicate the same Service Details for a number of days by designating a date range. This will copy all details from the “original detail” and all billing details will be copied for the amount of days entered.

Complete the first service detail box and then click “Copy Service”.

A date range screen will appear. Choose a “TO” date and click COPY.

A series of Service Details will appear for the date range that was chosen.

Note: In the above example there are three days that are being billed while all of the other details are the same.

Other Editing Tools

Clear Row If the information in a service detail is incorrect, the user can click the Clear Row link to delete the contents of a specific row.

Billing Preview If the user would like to see if the note will submit successfully, click the Billing Preview link. This can also be helpful to identify any potential issues with the billing configuration that might cause the note to be denied by the payer.

-Example of a note that will submit successfully.

-Example of a note that will not submit successfully and will require an update to either the client record, clinician profile or rate mappings in system data maintenance.

View History Clicking this button will show the “life” of the note.

Once the button is clicked; users can see “who” was involved with the note, “what” fields and values were changed, and “when” details were updated/added.

Regulation Notice:

Below are the regulations for all Service Documentation types. Take note that a user can make changes to a note after it’s been ‘submitted’ in our system if rejected by a reviewer or finance admin prior to it being billed. The note should re-stamp with the most recent E-Sign submission date.

Corrections in the Service Record

It is important that the information contained in the service record is accurate. Provider agencies should have sufficient protocols and internal controls in place to assure that all documentation in the record is correct and complete. All staff should make an ongoing effort to assure that the information in the service record is correct. As changes occur in people’s lives, updates are expected, e.g., updating the individual’s new phone number, etc. However, there is a difference between updating information in the service record and making corrections to errors in documentation.

The integrity of the original documentation that was entered into the service record to substantiate service provision and reimbursement of that event must be maintained, even when the original documentation contains an error. Subsequent revisions, changes, or corrections in the record must adhere to the following procedural guidelines. Changes or modifications to the original documentation for the purpose of making a correction can be made at any time, when appropriate, and shall be carried out in the manner described below; however for quality assurance and reimbursement purposes, all necessary documentation or corrections to support billing shall be properly completed within seven working days that the staff person is at work from the date the service was delivered, or from the close of the service period for certain day/night or twenty-four hour services. Therefore, for billing purposes, corrections must be made within these prescribed timeframes.

Electronic Records

Agencies which utilize an electronic service record shall develop procedures that staff is required to follow whenever corrections are necessary in the service record. These procedures shall include the following requirements:

Corrections must be made by the individual who recorded the entry; APSM 45-2

Corrections shall be electronically signed and dated.

The original text shall not be deleted.

An explanation as to the type of documentation error shall be included whenever the reason for the correction is unclear [e.g., “wrong service record”].