Service Notes

The Sedcare Electronic Health Record System Can Help You Create High Quality Service Documentation

Service Notes are automatically ‘tied’ to the Goals and Interventions in the Service Plan. Service Notes have a Goal, Intervention, and Outcome structure. Use an innovative SEDCARE utility that allows supervisors to Review Notes and make comments on Corrective Action before approval. Be confident that the ‘Zero Defect’ measures built into SEDCARE ensure compliance with Documentation Standards, Provider Privileging, and Training requirements.

  • Create Notes: Select Goals and Interventions from the Service Plan for each Service Note. Enter individualized narratives to describe the Purpose of the Contact, details of the Intervention, the consumer’s Response to the Interventions and an assessment of the consumer’s Progress toward the Goal. Select Objective Ratings for the effectiveness of Interventions and progress toward Goals.
  • Review and Approve Notes: Supervisors post comments to staff on Corrective Action and staff ‘Rework’ the Service Note. Use SEDCARE’s innovative query system to view lists of Service Notes at each stage of completion for Review, Reworking, Approval, and Electronic Signature. Approving Notes without review is an individualized user option.
  • Get Zero Defects Results: Service Notes are automatically checked for Privileging of Provider, presence of a Funding Source, current status of Service Authorization, and a number of other system edits to help approach ‘zero defects’ in Service Notes (and ‘Audit Proof’ Claims).

Continue in Clinical Functions by going to: Assessment ¦ Assessment Summary ¦ Service Plans ¦ Case Management

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Service notes can be a key factor in poor audit results; let Sedcare help minimize the potential for low scores.

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