Most organizations have a two level review:
- Sign – done by the provider of the service once the records have all been entered and reviewed.
- Approve – done by their supervisor after reviewing the records and agreeing with how they have been entered. If the supervisor does not agree with the entry, the supervisor can use the Reject button, and the record will be returned to the provider for editing. (See Editing Records in Case Manager for more information on editing signed records.) After the provider has made the appropriate edits and then Signed the record again, the record returns to the supervisor for Approval.
Ideally, each provider would complete all records at the end of each day and the simplest method for signing is using Provider Review. However, when that is not possible, the records will remain available until signed. The records will also be reflected on the Sign/Approve pages of the provider’s supervisor, empowering the supervisor to ensure the records are signed on a timely basis.
Signing records as Provider
When providers want to view what records they have yet to sign or those that have been rejected by a supervisor, click Sign.
The Service Record Management page displays with list of all Service Records presently in a pending state of Rejected, Not Signed and Signed. The service records are grouped by date and each date includes a count of how many records are at each status.
Rejected—Records that have been reviewed and have been rejected by the reviewer. The reviewer will be able to make a note and the record will go back to the original author/provider to make appropriate edits
Not Signed—Service Records that have data entered but have not yet been signed by the author/provider/supervisor
Signed—Service Records that have been entered and signed by the author/provider/supervisor.
To review and edit the records, click the check box next to the date and you will see all persons that you served, and the consumer card will show the status of the service record indicated by color.
- The Red box next to the card indicates that there are issues with the record, something is missing or incorrect.
- Yellow indicates a warning, something is missing but it is not required—only recommended to be added/edited.
- The Green box indicates that the record meets all required aspects and is ready to be signed/approved.
Alternatively, click the carat beside the date and you will see a list of the Service Sessions that you completed on that date.
To review a session, click the Name and Location and the actual session displays. From there you will be able to Sign/Approve/Reject records exactly the way you would have done it at the end of the session. (See Session Management documentation for detailed instructions on using this interface to Sign/Approve records.)
To identify what is missing from a record, click the time block. Messages will inform you what’s missing or incomplete.
You will then be given the opportunity to edit an End Time, Delete, Sign or Transfer the record directly from this window.
Use the calendar and clock icons to enter date and time
Transfer is used to move this consumer record to a different session or correct data entry mishaps in the event of an incorrectly entered Location, Activity, Date, Time and/or Provider. You will not be able to change Location, Activity, Date, Time and/or Provider until you then transfer the record. A window opens that allows you to make changes as needed.
Once you have made necessary edits, click Save & Close to return to the original page.
Other errors may include the need to provide a Case Note, chart Progress and/or to respond to a required Support. These rules are controlled by your organization and are setup by Management to follow your process rules.
In every case, the red message will indicate which element(s) are missing. Click the appropriate button on the Consumer Card to resolve the pending issue.
Supervisor Approval and Signing
For Supervisors, Approvals work the same as the Sign steps above. The only exception is that you will click Approve rather than Sign. The Approve page is available based upon a security role configuration.
For Supervisors who also provide services, the sign page displays a count for the service records you’ve entered as well as the records of those who work for you. If the session indicates zeroes next to the date and you click on the date—you will get a message that reads “No Records Found” since you do not have any records to sign.
Clicking the carat next to the provider’s name displays the details for each session created by that provider on that date. Click the sessions themselves to see the session details.
For all users, once all the records have been signed/approved the records will disappear from the Sign/Approve screen and you will know then that your work is complete.