Service Notes – Part 2 (PD) 1 › palms-awss3...requirements. Please view and then save or print...

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Course Number 014-10-01

1Service Notes – Part 2 (PD)

This webcast includes spoken narration.

To adjust the volume, use the controls at the bottom of the screen. While viewing this webcast, there is a pause and reverse button that can be used throughout the presentation.

The written version of the narration appears to the right of the screen.



Certificates of Achievement will be available to SCs and SC Supervisors after completing all course requirements. Please view and then save or print your certificate in order to receive credit for this course.

For SCs and SC Supervisors, course requirements include successful completion of a pre‐test and a post‐test.



Hello and thank you for viewing this webcast about service notes. My name is Sonya Hipple and I work for the Office of Developmental Programs as the Supports Coordination Organization (SCO) Lead in the Central Office. I will be your narrator for this webcast.



The objectives for this course are:

‐ Remember the basic information on the importance, requirements, and components of a well–written service note

‐ Recognize the key components of an ODP‐acceptable service note when documenting activities related to incidents, monitoring, ISP meetings, and outcomes

‐ Identify the purpose of and determine when to use the Service Note Follow‐up Feature

‐ Understand and apply the key factors in differentiating between billable, non‐billable, and excluded activities and

‐ Explain the role, responsibility, and process of the SC Supervisor to review service notes to ensure quality documentation and accurate billing



Based on information gathered through ODP’s SCO Monitoring Process review, this Part 2 training provides more in‐depth information about writing Service Notes to meet ODP requirements for quality and billing. The training also provides information for SC Supervisors on how to review Service Notes in order to meet the ODP standards identified and discussed during the training. The Service Notes Basics 2013 – Part 1 was required training in 2013, and is now available as professional development. If you are a new SC or an SC who did not take the Part 1 required training in 2013, it is recommended that you view Part 1 before viewing this webcast.



As you know, documentation is a necessary and important part of a Supports Coordinator’s work. For every contact that an SC makes, he or she also enters a corresponding service note. The service note will highlight and summarize important points and clearly refer to where further details can be found, without duplicating every detail. It’s important to include enough detail to give the reader a snapshot of the activity.

The key here is that service notes need to be concise, and focused on the main issues.

The next few slides will provide examples and will illustrate what a clear, concise and accurately detailed service note should look like according to ODP’s expectations.



You’ll recall from the Service Notes Basics 2013 – Part 1 training, that it’s key to note the 4 “Ws:” when, what, who, and where. Aside from capturing the 4 “Ws,” ask yourself:

‐ Is the service note about what the SC did, or is it about the individual and what he/she is doing in his or her life [person‐centered]?

‐ Is the service note, subjective or objective?

‐ Is the service note focused on the individual and events occurring in their life, or is it focused on the SC and his or her actions?

‐ Does the service note content reflect activity that justifies the units billed?

Now let’s take a closer look at these questions and what service notes could look like for each example.



In these examples, the SC Activity service note does not include the 4 “Ws” and is not person‐centered. Whereas, the Individual Information service note describes exactly what the individual wants and who is to be a part of his ISP meeting. The Individual Information service note is the acceptable service note as it’s keeping the focus on the individual, as well as addressing the 4 “Ws.”



In the Subjective Language service note, the information may or may not be connected to facts. Service notes should not reflect the feelings or opinions of the SC.

In the Objective Language service note, the SC describes what was discussed or what occurred –what was seen, heard, or directly observed. Using objective writing means that facts are presented free of assumptions and opinions.



In the Other People service note, the note only depicts what was going on in mom’s life right now and only her concerns, not Ben’s. This service note is not billable as it does not reflect any of the Supports Coordination services of monitoring, locating, or coordinating.

In the Individual‐focused service note, the SC captured the change in the family situation and how it’s going to impact Ben’s life, as well as coordinate possible services.

Now that we have gone through the key areas of documenting a service note, let’s look at specific and more common categories of service notes starting with incidents. All service notes in this training are considered ODP‐acceptable unless otherwise stated.



As an SC, there are a number of alerts in HCSIS that notify you that an incident has been created

for the individuals you support. The Incident Management (IM) alerts that you may receive are:

‐ Incident First Section is submitted

‐ Incident is approved by County with comments

‐ Incident is closed

‐ Incident is closed by Region with comments

‐ Incident is not approved by County

‐ Incident is not approved by Region

‐ Incident is reclassified in Final Section

‐ Incident Report is finalized and

‐ Extension notification is filed

It is important that SCs review all HCSIS alerts daily, as all of the alerts expire after seven days.

When you receive any IM alerts, you should review the incident in HCSIS. While repeating all the

details (copying and pasting entire sections of the report) in to the service note is not necessary,

you should still highlight the specific points to put the incident into context, and refer to the

actual report for the details.

Example Service Note: “Received and reviewed Incident #xxxxxx Report filed on [when]

mm/dd/yyyy. Allegation of Individual to Individual abuse [what]. John [who] was apparently

struck by another individual at work [where], only a minor injury. Staff removed other individual

from area and John is safe. See Incident #xxxxx for specific details.”



On the slide is an example service note taken directly from HCSIS. As you can see it includes the 4 “Ws” and it is a summary instead of a verbatim copy of the report.

This example perfectly points out:

‐When ‐ the date it happened

‐Who the target was without breaking HIPPA compliance

‐What action did the staff take

‐Where you can find further information in the incident report

Now let’s look at service notes and monitoring.



The comments included in the ISP Monitoring form needs to contain information about the individual’s current supports and services, individual preferences, and priorities identified in the ISP. Information within the form should also include a detailed review of the progress and effectiveness of outcomes identified in the ISP.

The monitoring form should be used to capture the details of issues and concerns identified during the monitoring. The service note should document that the service was provided. The service note does not need to repeat all of the information documented in the monitoring form, however, what should be included are:

‐When the monitoring took place

‐Who was present during the monitoring

‐What was reviewed during the monitoring visit

‐Where the monitoring occurred and

‐ Any issues or concerns that were discussed during the monitoring visit

What service notes do is summarize the visit and services as stated and are used to document follow‐up activity related to issues discovered.

The ISP Monitoring training will provide details regarding how to specifically document issues and comments that were discovered during a monitoring visit.

In addition, there may be times that you gather information during a monitoring that really doesn’t fit well into any of the monitoring questions, but is still important to note. For example, someone is moving. You should be sure to document this information in the service note as well as at the end of the monitoring form.

The next four slides illustrate how service notes should capture monitoring visit information.



As you can see in Example #1, the SC performed follow‐up regarding the individual’s pain management; reviewed medications and there were no changes; and reviewed progress toward the outcome actions. This service note meets ODP expectations.



Example #2 captures health and safety, review of service utilization, review of ISP outcomes and the progress made towards them, and overall satisfaction with current services. In this example, the SC did a good job of detailing all of the needed information in the service note, as per ODP expectations.



Every monitoring that occurs should include the detailed progress made on the individual’s outcomes.

In the Example #1 service note, the SC has documented that progress was reviewed towards implementation of Armando’s ISP and validated that his services are consistent with needs and desired outcomes. This is the detail that ODP is expecting to see in service notes.



As seen in Example #2, the SC recorded that Jill, with her habilitation aide, Joan, have been spending time working on her shopping skills during the last month, and will continue to work on this outcome with Joan. In this service note, the SC again meets ODP expectation by detailing what outcome is being worked on and by what methods.

Next let’s look at how to document the ISP meeting.



When capturing information taken from the Annual ISP Review meeting in a service note, it is critical to include the 4 “Ws.”

While ODP has a number of forms to be completed at the Annual Review meeting, keep in mind that the meeting itself still needs to be person‐centered, and focused on the individual’s preferences and priorities.

So, in addition to documenting that the forms were completed and signed, the service note should also include what was discussed at the meeting regarding:

‐What the team discussed about the person’s outcomes

‐What was reviewed and updated in the ISP

‐What actions will be taken and who’s responsible and

‐What issues will require additional follow‐up



In Example #1, you see that the SC identified who was there at the meeting and discussed the forms that were completed, but mostly focused on Emily’s desired outcomes for the upcoming year and her career goals. This service note is person‐centered and details out what occurred during the ISP meeting, therefore meeting ODP expectations.



In Example #2, the SC again identifies all team members present, discusses all required forms and options regarding providers, reviews the SIS with the team, and just like in Example #1, the service note is person‐centered and maintains focus on the individual during the meeting. This is another good example of what ODP expects to see in service notes.

At times, an SC will encounter issues that need to be followed‐up on, but do not affect the health and safety of the individual. The next slide demonstrates two examples of how to capture this type of information into a service note.



In this first example, the SC noticed the issue of the garbage disposal and made sure to ask George if the landlord was aware of the issue.



In the second example, when the SC returned a month later, the disposal was still broken and the SC made a note to follow‐up with George’s staff.



After describing who, what, when, and where, service notes also need to include the expected next steps that will occur as the result of the activity. Your next steps as the SC are to get answers for the following questions:

‐What actions need to occur and why? and

‐Who is responsible?

Identifying this information focuses on actions that need to occur to resolve issues and make progress towards outcomes, and it allows everyone to know what is expected of them.

HCSIS has a helpful tool to keep track of follow‐up that needs to be completed. This helpful tool we’re referring to is called the “Follow‐up Feature.”



The Follow‐up Service Note allows you to set reminders for future action that is needed based on the service note.

The follow‐up feature is an optional tool to assist SCs with managing their caseloads. When SCs select the follow‐up option, they enter a due date for the follow‐up. HCSIS will generate an alert to the SC eight days before the selected due date. If the selected due date is less than eight days away, the alert will be automatically generated and immediately sent to the users.

This feature is meant to be a helpful reminder and while it is not mandatory, it can be very beneficial in assisting SCs in keeping track of issues that require follow‐up.

For example, this feature can be used when an SC receives information during a phone call that requires further analysis, or when an individual has non‐statutory monitoring frequency. In addition, Follow‐up Notes may be necessary based on findings from the monitoring instrument or a previous service note.

Let’s look at how the Monitoring Service Note would appear when we select the follow‐up feature.



In this example, the SC picked Required under the Follow‐up option, which allowed her to place a follow‐up due date – as shown. An alert would have been sent to the SC on 01/02/2014because the follow‐up date is less than eight days away.

The SC also documented why follow‐up is required, as he will need to contact the job coach provider regarding job coaching services and when a new job coach will be starting.



For this ISP follow‐up service note example, the SC has set herself a reminder to notify the providers once the plan has been approved.



As you can see, the SC plans to contact the family to get information about how the individual is doing.



This example involves imminent risk of the health and safety of Rachel and her housemates. The SC selected the follow‐up option, and set the follow‐up due date as the next day due to the severity of the incident. The SC wanted to ensure that all follow‐up was completed and that he documented everything that occurred.

You have just seen examples of how to use the Follow‐up Feature for service notes. Now let’s discuss what activities are considered billable, non‐billable, and excluded.



According to the ISP Manual, Section 13.17: Supports Coordination, activities included under the SC’s primary functions of: locating, coordinating, and monitoring functions define the activities to be documented as billable.

For a detailed description of what these activities are, please reference the Billable, Non‐billable, and Excluded Activities document in the Resources section where you launched this webcast.

Please note ‐ SC Supervisors can bill for any activity that is locating, coordinating, and monitoring in the absence of an SC. It does not have to occur while carrying a caseload, it can be while the SC is out of the office at a meeting. All administrative SC Supervisory activities such as, reviewing and approving ISPs, fiscal year renewals, and service request forms are non‐billable.



How the Service Note is billed depends on:‐ Enrollment status of the person (Waiver or Non‐Waiver) and‐Whether or not the billable box is checked

When the box on the service note is checked as billable (or non‐billable), HCSIS compares the individual’s enrollment status and automatically links the service to the appropriate funding stream.‐ If they are enrolled in a Waiver, the service is billed to the appropriate Waiver and ‐ If they are not enrolled in a Waiver they are billed under Base

SCs need to be deliberate in making sure that the billable box is checked or unchecked depending on the type of service they are providing.

One example of non‐billable services that could be documented is the time spent driving to meet with a person to provide services, or to attend a meeting. While travel is considered a non‐billable activity, some SCOs request that their SCs enter in a non‐billable service note for this time. Please consult your supervisor about your SCO’s policy.

The billable box is greyed out when the Medicaid screen is not completed or answered “No.”



In order to bill a unit for service, it must last for the entire 15 minutes. In the first example above, leaving a voicemail message takes less than 15 minutes to complete. The detail of this service note does not support the 2 units, or 30 minutes billed. Because the information in this service note does not indicate 15 minutes of service, this service note should have been entered as 0 units.

The key is looking at all that is involved in the activity – your preparation, the contact, your follow‐up, and, if applicable, the documentation – if all of that time totals at least 15 minutes, within the same day, you can bill for that service. This includes the time it takes to:

‐ Read the mail or attempt the call

‐ Respond to the mail or the actual time of the call

‐ Follow‐up as needed to address the issue (and/or file the letter) and

‐Write your service note – In order to account for the time it takes to enter the service note into the units for the overall services rendered, the service note needs to be entered on the same day as Date of Contact

In the second example, the SC documented everything he did for George’s new ISP Meeting date and time, as all of these activities met the 15‐minute requirement, the SC was able to mark the service note billable.



When entering a service note, you will notice additional category and sub‐category fields that are available for selection.

These fields are specifically used by the Office of Long‐Term Living (OLTL). However, if any of these fields are a better fit and are applicable for your particular individual’s service note, they are available for your use as well. For a detailed description of these categories and sub‐category fields, refer to the HCSIS LMS Job Aid under Service Notes for more details.



It is ODP’s expectation that one of the many roles of the SC Supervisor is to review and/or edit the service notes entered by the SCs they supervise. As an SC Supervisor, it is your responsibility to review service notes regularly and assure that they are adhering to the requirements and concepts listed throughout this training, including ensuring that the service note contains appropriate billable activity.

When SC Supervisors review service notes, a supervisor edit field opens up below the service note field. When editing the content of the service note, the supervisory edit field is mandatory to identify the change. Any supervisory edits should be shared with the SC and used as a training opportunity.

Review of service notes by the SC Supervisor should be completed within the billing cycle timeframe. After the billing cycle, all service notes will be read only. Due to the regularly scheduled service note claim sweep within PROMISe, review must be completed prior to the 4th and 19th of every month.

If the SC Supervisor completes an activity around monitoring, locating or coordinating for an individual, that service is billable to the SC Supervisor. When they complete the service note for the activity, the supervisor edit field is not mandatory.



Look at the service note on this slide, would you edit this service note?



If you answered, yes – you would be correct! So, what you want to see is:

‐Who was there; identification of the team members

‐What was reviewed in the ISP and what updates were documented

‐What outcomes were discussed and decided on

‐ Is there any follow‐up needed? If yes, who is responsible? and

‐ Specifically, what documents were reviewed



In the Service Notes Basics 2013 – Part 1 training, SCs learned the difference between objective versus subjective service notes. Service notes in HCSIS should be objective. If you encounter this service note while doing your supervisory review, what would you change?



This service note is subjective. The SC does not provide any objective or observable reason why Jolene is happy. Also, the documentation of activity that does not pertain to locating, coordinating, and monitoring (in this case, patting Jolene on the head) should not be included in service notes.



As you review this service note, can you identify what issues are occurring?



Issues that are occurring with this particular service note are:

‐ Isabel’s health and safety. SC documented that, according to mom, the doctors say Isabel cannot consume food by mouth. However, the service note goes on to say that the SC saw Isabel’s niece give her an ice cream cone. She should not be eating an ice cream cone, per her doctor.

‐ The SC does not document in this service note what action, if any was taken to protect Isabel.

‐ As an SC Supervisor reviewing this service note you want to know what the follow‐up was to this health and safety issue.

‐ Any follow‐up from a discussion with Isabel and her family, a discussion with the SC Supervisor, an offering of additional services, and/or reporting the issue to the AE should be documented in subsequent service notes.



Another area of Service Notes that you, as an SC Supervisor, should be reviewing, is the number of units being billed. Specifically, you should ask, “does the Service Note support the claim, or amount of units entered?”

As you can see in the two examples above, the Service Notes do not support the units billed.

In Example #1, voice mail messages do not meet the criteria of taking 30 minutes, which is the total of two‐15 minutes units, for an SC to complete. Supports Coordination services must occur for a full 15 minutes in order to bill for one unit. In this example, the detail of the service note does not support the number of units billed. The service note should be marked non‐billable and 0 units should be entered due to the entire activity (voice mail and writing of note) not needing a full 15 minutes to complete. The SC Supervisor is responsible to edit this service note and change the units to 0.

In Example #2, completing the PUNS and printing it out does take some time. However, six units equals one and a half hours of work. The SC does not provide enough information in this service note to justify one and a half hours of supports coordination services. The SC Supervisor should meet with the SC who wrote this service note to determine how much time was actually spent on the activity and edit accordingly.

As stated previously, any supervisory edits should be shared with the SC and used as a training opportunity. During this review, it’s important to remind the SC that it’s critical to look at all activities that are involved, and if all of that activity totals at least 15 minutes, within the same day, the SC can bill for one unit of service. In order to account for the time it takes to enter the service note into the units for the overall services rendered, the service note needs to be entered on the same day as Date of Contact.

You may also notice a trend of service notes that do not support the units billed with some SCs. When you identify this kind of issue, it is important that you, the SC Supervisor, assist the SC with understanding the billable unit requirements and provide the necessary guidance and further instruction.



Service notes are reviewed by ODP, other state offices, and the federal government. In addition, they are routinely reviewed during legal proceedings, for example, when an individual exercises the right to an appeal. It is important that all service notes accurately reflect the amount of time the service was being provided as well as a detailed description of that service.

As you have just seen, the SC Supervisor’s role of reviewing service notes plays an integral part in the service note process. Reviewing service notes allows an SC Supervisor to know what is going on with the individual, to guarantee that follow –up actions are occurring appropriately, as well as ensuring service notes meet ODP expectations.

Service Notes – Part 2 (PD) 41


This online course discussed the key areas of:

‐ Coordination of service notes documentation including linking to other areas of documentation such as, Incidents, ISPs, and Monitorings

‐ Using the Follow‐up Feature in HCSIS as a helpful reminder and asking the questions: what actions need to occur and why, and who is responsible?

‐ Differentiating what activities are billable, non‐billable, and excluded

‐ Roles and responsibilities of the SC Supervisor in the review of service notes and additional actions that need to be taken



This webcast has been developed and produced by the Office of Developmental Programs Consulting System on behalf of the Pennsylvania Department of Public Welfare, Office of Developmental Programs.

Thank you for participating in this lesson.



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