From:                              Widmayer, Tess

Sent:                               Wednesday, April 25, 2012 10:13 AM

To:                                   Alice Belford - MHS BPSR Kinesis North; Allison Sepulveda - San Diego Deaf Mental Health Services; Amelia Ford - Casa Del Sol; Ami Roeschlein - UCSD Co-Occurring Disorders; Anna Ennis - Heritage Clinic East; Anna Grellert - Exodus; Annette Witt - UCSD Gifford; Areta Crowell - Staff; Knight, Elizabeth (Betsy); Brandi Marcoe - NAMI - Family & Peer Support Helpline; Cara Evans - Providence; Gardner, Carter C.; Cecily Thornton Stearns - Providence - Catalyst; Colette Lord - Jane Westin Wellness and Recovery Center; German-Marquez, Connie; Cynthia Halpin - Exodus; Dixie Galapon - UPAC CTC; Erika Keus - CalWorks; Evelina Jaime - Project Enable; Fahimeh T. Peifer - MHS Case Management North; Jennifer Hurlow-Paonessa - Project Enable Geriatric Specialty; Jennifer Whelan - Douglas Young Clinic; Jim Fix - PERT; Juan Camarena - Maria Sardinas & Maria Sardinas Puentes; Juan Medina - San Diego Employment Solutions; Julie Cole - Hope Connections - MHS; Karen Hempstead - Areta Crowell Director; Kathi Anderson - Survivors of Torture; Kathleen Leverette - MHS Compliance; Sorahan, Kathleen; Kathy Robbins,  MFT - BPSR Vista; Kathy Shoemaker - Exodus; Kendra Makey - Center Start ACT ; Kim Hendricks - North Star ACT; Kimberly Shultz - Acting PM - MHS Case Management North; Laura Reyes - Program Coordinator - Southbay Guidance Center; Linda Hammond - CRF Legal Entity - President; Linda Richardson - MHS N.Inland; Lisa Bertelle; Fernandez, Luz M.; Mahvash Alami - Survivors of Torture; Maria Morgan - Kickstart; Marty Adelman - Council of Community Clinics; Mary Wheeler - Casa Pacifica; Mary Woods - Telecare - ACT, Access and Transition team; May Vang - East Wiind Socialization Center; Melissa Beals - IMPACT; Michael Juan - Program Director - South Bay Guidance Center; Michele Cannon  - SD MHC for Deaf; Michelle Romero - Exodus - Central Connections; Minerva Morales - Family Health Center Logan Heights; Myra Buby - Family Health Center Hillcrest; Natalie Gillespie - MHS North Coastal; Nikoo Z. Sadatrafiei - CalWORKS Escondido (zsadatrafiei@mhsinc.org); Patricia Judd - UCSD; Patricia Tapia - Heritage Clinic -  Director; Paula Concalves - CRF QI; Payal Beam - MHS North Coastal Mental Health Center; Rachelle Kehoe - MHS Contract Compliance - Adult Mental Health; Sanyana Saxena - UCSD Outpt Services; Scott Elizondo - MHS Kinesis North; Susan Lund Heritage Clinic NI  - Program Director; Tammy Summers - MHS - Center Star ACT; Toan Cao - UPAC Eastwind; Troy Boyle - CRF Impact; Watson, Greg; Yi Chuan Cheng - Heartland Center; Zina Salem - Chaldean and Middle-Eastern Social Services ; Barri Levin - Halcyon Center; Dan Maccia - Vista Balboa; Ginger Wotzka - Casa Pacifica - CRF; Lisa Bertelle - New Vistas; Martha Noderer - Jary Barreto; Mary Wheeler - Casa Pacifica; Megan Partch - Starting Point ; Michelle White - Alpine Starting Point; Natanya Glezer - New Vistas; Paul Knight - Isis Center; Rhonda Mata - Casa Pacifica; Tara Bogs - Turning Point Crisis Center; Tashia Kane - Uptown Safe Haven;  Barent Mynderse - Rady Children's Hospital; Alaya Ben-Tal - Rady - Developmental Eval Clinic; Allison Sepulveda - SD Deaf MHS; Angela Chen - UPAC; Angulo Aidee (SDUSD IOP); Autumn Bailey - The Bridge; Betty Plewak - Mental Health Resource Center; Beverly Laning - COP North Coastal - Vista Way; Bill Simpson - CRF - Nueva Vista Family Counseling; Carrie Kintz - FFA/Stepdown - SDCC; Cheryl Alexander - Jewish Family Services; Crystal Luna - MHS TBS; Cynde Roth - MHS - Frontier; Cynthia Jaurequi - Community Circle Spring Valley; Dawn Jennings - South Campus RCL 14; Debbie Shriver - North County Lifeline Oceanside; Denise Kerwood - Cabrillo Assessment Center; Denise Kerwood - New Alternatives - CAC; Dori Gilbert - YMCA; Eileen Quinn-O'Malley - Fred Finch Polinsky Day Rehab; Elizabeth Tebo - Clark Adolescent Treatment Center; Erin Murphy - STEPS; Gala Goodwin - Victor Santa Rosa; George Montoya - Rady CES; Golby Rahimi - Families Forward - MHS; Hillary Sloan - NA - Herrick Center; Jacqueline Gardiner - CAT YAR - MHS; Jacqui Small - Cajon Valley - NA; Jamae Marcinko  - FHC - Community Circle Central; Jeff Goodman - Stepdown EPSDT - SDCC; Jeffrey Olson - Developmental Eval Clinic - Rady; Jenelle Kargacos - Life School; Julia Darling - COP NC & San Marcos Academy; Karen Giannini - VHLAC Escondido; Karyn Donado - Families Forward; Klea Galasso - NA TBS; Kristin Cremer - VHLAC Ramona; Larry Fortin - Green Oaks Ranch; Laura Rogers - Fred Finch Wrap; Lisa Hazlewood - COP NI & Rancho Bernardo; Lori Barnes - Discovery Hills and Discovery Valley - SDCC; Mark Gotbaum - Juvenile Court Clinic - Vista Hill; Mary Ellen Baraceros- Cornerstone - Providence; Melissa Haupt - Hillcrest DT - NA; Michael Falcone - SDYS CAT ; Michelle Deitz - Polinsky Med Center (Rady); Nick Montano  - Para Las Familias; Rebecca Bernard - RCL 23 & 14 - SDCC; Rebecca Raymond - Crossroads; Rhaelynne Scherr - SAY CAT & SAY Marshall; Roberto Suarez - YES; Robyn Ramsey - ALLY Southbay & National City; Shaly Haddadd - Chaldean and Middle-Eastern Social Services ; Shirley Culver - San Diego Unified ; Steven Jella - The Bridgman Home/The Bridge; Susan Lawlor - Palomar Fallbrook; Tamara Marthens - NC Lifeline; Terry Maxson - Harmonium - Parent to Parent; Virgina Bial - Kidstart; Wendy Panagos - East Region Outpatient - SDCC; Yuka Morita - Marcy Day Rehab; Angela Rowe - Incredible Families ; Araseli Lewis - CRF CARE; Bruce Wexler - Fred Finch Dual Diagnosis; Carol Burns - Clinical Director - UPAC; Carole Doherty - CAT - South Bay Community Services; Carrie Kintz - FFA/Stepdown - SDCC; Castillo, Josie; Engelman, Celia; Cobb, Diana; Colligan, Laura; David Baker - Victor Lodi; Fitzgerald, Anne; Gary Stewart - Rady Behavioral Crisis Center; Gary Youssef - COP Central; George Montoya - Rady CES; Gorman, Jane; Jacqueline Gardiner - CAT YAR - MHS; Jacqueline Gardiner - CAT YAR - MHS ; Jerri Coast - Vista Hill IOP; Judy Parker - Unified Day School; Julie Mancia - MHS School Based; Julie McPherson - Douglas Young; Lisa Turner - Childnet ; Massoth, Sharon; McCawley-Self, Julie L.; Michelle Atkins - SDYS Counseling Cove; Mike Miller - MAST; Picker, Jamie; Rebecca Bernard - RCL 23 & 14 - SDCC; Rex Sheridan - San Pasqual Academy; Robin Bowman - Victor Redding; Stacy Musso - New Dawn; Stephanie Rosen - MHRC & Early Childhood Mental Health - SDUSD; Steward Holzman - MTFC-P  SDCC; Tamara Fleck-Martens - Casa De Amparo; Tammy Runge - Dual Diagnosis Services for Probation Institutions (SAY); Walker Dewitt - MTFC SDYS; Watson, Greg; Zina Salem - Chaldean and Middle-Eastern Social Services ;  Barent Mynderse - Rady Children's Hospital; Anna Grellert - Exodus; Baron Herdelin-Doherty - YMCA; Chris Rich - UCSD; Christopher Marcis - Episcopal Community Service; Cynthia Jackson - Heritage Executive Director; Dave McCaslin - SDCC Legal Entity; David Monroe - Victor Treatment Centers; Dina Zayat - South Coast Children's Society; Donald Stump - NC Lifeline ; Ed Martinez - BHG Parent Org; Evalina Jaime - Neighborhood House Association; Fran Butler - FHC Parent Org; Gary Hubbard - Telecare; Ginny Romig - Providence Parent Org; Holly Younghans - Episcopal Community Services; Irene Saper - Palomar Parent Org; Kathi Anderson - Survivors of Torture; Kathie Jacobson - Fred Finch ; Kathryn Lembo - South Bay Community Services Parent Org; Kent Dunlap - Stars Behavioral Health Group; Kimberly Bond - MHS Parent Org; Leslie Elion - Deaf Community Services; Linda Hammond - CRF Parent Org; Luis Leon - Prime Health Care; Margaret Iwanaga-Penrose - UPAC; Meg Norton - Rady Parent Org; Michael Bruich - New Alternatives Legal Entity; Michael Carr - Director, SAY San Diego; Mike Bloom - UCSD; Rob Dean - Vista Hill Parent Org; Rosa Ana Lozada - Harmonium; Sharon Delphenich - Casa De Amparo Parent Org; Shirley Culver - San Diego Unified ; Steve O'Kane - Council of Community Clinics; Suzanne Purdy - Paradise Valley Hospital; Walter Phillips - SDYCS Parent Org; Winifred Wechsler - Phoenix House; Zina Salem - Chaldean and Middle-Eastern Social Services

Cc:                                   Garcia, Piedad; Lang, Tabatha; Malcarne, Deborah; Palid, Anna; West, Virginia; Edwards, Frances; Koenig, Yael; Solomon, Michele; Anderson, Kathy; Benitez, Carlos; Ellingsen, Paul; Elwood, Rosinete; Garcia-Moreira, Margarita; Hansen, Stephanie; Hiltsley, Michalene; Jones, Steven; Kobold, Helen; Lea, Samantha; Loo, Adriana; MacDougall, Deborah L.; Mertins, Karl; Miles, Elizabeth A.; Milow, Candace; Newcomer, Brian; Raby, Michelle M.; Rosengarten, Ian; Tormey, Timothy; Tran, Trang; Widmayer, Tess; Amy Chadwick - CASRC; Ana Barrett - Director of Regulatory Accounting - CRF; Andres Sciolla - UCSD Outpatient Psychiatry; Anita Poellnitz - CRF; Ann Harris - Clinical Director - Hillcrest House - NA; B. Them - Prime Healthcare; Cara Evans - Providence; Carmen Moon - Providence TAY; Carol Davis - Optum Health; Carol Neidenburg - CCHEA; Chelle Sutyak - Casa De Amparo; Cynthia Jackson Kelartinian - Heritage Clinic - Executive Director; Dannica Sannicandro - UCSD; David Taylor - VHLAC Escondido; Denise Kerwood - New Alternatives - CAC; Doug Reiss - Harmonium; Emily Dibben - Casa De Amparo; Emily Trask - CASRC; Erin Lae - Dual Diagnosis Program Coordinator - SAY San Diego; Gina Hungerford - Staff Clinical Therapist - National Center for Deaf Advocacy; Golby Rahimi - Families Forward - MHS; Harriet Stupp - Manager of Provider Services - Optum Health; Holly Younghans - Episcopal Community Services; Jamie Schaubel - San Diego Unified; Jennifer Cassidy - San Pasqual Academy; Julie Cole - Hope Connections - MHS; K. Fawley-King - CASRC; Karen White - Families Forward Admin; Kathleen Leverette - MHS Compliance; Kim Wilson; Kristine Tiernan - Alpine Special Treatment Center; Laura Beadles - Behavioral Health & Communit y Services Director - SDYS; Laura McLarin - Fred Finch - Wrap - QI; Laura Otis Miles - MHS VP; Laurie Rennie - SAY San Diego; Lea Bush - Positive Parenting - Jewish Family Service; Leean Couch - MHS - QI; Maria Palomo - North County Lifeline; Marie Saragosa - San Diego Unified; Melinda FurFuro - SDYS Family Partners Program; Michael Jones - The Bridge - Division Director; Michael Mays - South Coast Community Services - Billing; Michelle Molnar - Financial Administrator - Providence Community Services; Mike Carroll - Action Regional Manager - Heritage; Mike Phillips - JFS Patient Rights; Minola Clark Manson - San Diego State University; Myisha McNair - San Diego Unified; Nathan Aish - MHS QI; Nick Mortaloni - PEI - SDYS; Nora Cole - FHCSD - MHS Project Manager; Orv Coonce - MHS; Pam Wright - South Bay Community Services; Pamela Bryson - Program Manager - Vista Hill Smart Care Integrated Health; Patricia Lazalde - Director of Behavioral Health - SDYS; Robin Bowman - Victor Redding; Sarah MacArthur - SDCC - Children's Wellness Program; Scott McGuirk - South Coast Children's Society; Somer Gardner - New Alternatives; Sue Robson - CRF; Terry Villacruz - Optum Health - Clinical Director; Tom Alexander - Fred Finch; Wanda Bennett - Telecare; Alan Higgins; Alisha Schnakenberg; Ana Briones-Espinoza; Carol Davis; Elsie Blancas; Gary Henry; Ines Russo; Justin Terrell; Keshona Rolle; Kim Stephens; Kris Summit; Kristie Tokar; Lauretta Jenkins; Nilsa Rubenstein; Ruth Kenzelmann; Adam, Kenneth; Astor, Katie; DeVoss, Angie BC; Eto-Barba, Sayaka; Gage, Yvonne; Gonzaga, Alfie; Monise, Lauretta; Murphy, Tammy T.; Redondo, Cecilia N.; Seal, James; Tabor, Monya; Thibault, Lori; Tregembo, Shelly; Wilcox, Jeanne; David Kneip - Exodus Recovery - QI; Debra Miranda - Rady QI; Debra Peltzer - Victor QI; Desiree Kane - Fred Finch - QI; Kelly Bordman - Families Forward QI; Laura McLarin - Fred Finch - Wrap - QI; Linda Nichols - NA QA; Lynne Kelly - NA QI; Misty Wilkerson - SDCC QI; Nathan Aish - MHS QI; Paula Concalves - CRF QI; Rebecca Tortorelli - Fred Finch Compliance; Susan Balla - SDYS QI

Subject:                          Progress Notes Corrections

 

Importance:                   High

 

This memo is sent on behalf of Michalene Hiltsley, Quality Improvement Supervisor

Due to an increase in the number of requests to void progress notes, the MIS planning team is working diligently to provide written instructions for how to manage errors within progress notes.  The number of scenarios that we need to work through to assure that clinical and billing issues are resolved appropriately is extensive.  We ask that you continue to be patient while we work out the details.  In the meantime we do have some preliminary information to share with you that may assist.  Please pass along the following information to each staff that write, review or manage progress notes.

 

Managing Errors in Progress Notes

When can a progress note be deleted?

A progress note may be deleted before it is final approved.  Once the note is final approved it may not be deleted – voiding is the only option.  Voided progress notes will always remain in the system and will show as “voided”.  If you do not want to view voided progress notes, please review your filter settings.

What can I change on a progress note and when?

1.    When the intervention is selected from the Client Plan as a “planned” service, it may not be changed once it is pulled in to the service entry – the field will show as gray.  If you have selected the incorrect intervention from a Client Plan, cancel the note and begin again selecting the correct intervention.

2.    When the intervention is selected as an “unplanned” service (not a part of the Client Plan), it may be edited once it is pulled in to the service entry.  If you have selected the incorrect intervention as an “unplanned” intervention it may be edited until the service is processed for claims.  The field will show as blue as long as you are able to edit it.

3.    The client assignment service, travel, and documentation time, as well as service indicators, are entered at the time of building the service entry portion – if you make an error in selecting the client assignment, time, and service indicators the system will allow you to make the correction until the time that the service is processed for claims. The field will show as blue as long as you are able to edit it.

4.    The date of service cannot be changed once it is selected in the progress note calendar.  Double check the date of service before you save the service entry.  If you have selected the incorrect date, cancel the note and begin again selecting the correct date.

What can I do to prevent the need to void a progress note?

1.    Double check the client name – make sure the note is written in the correct client chart.  

2.    Double check the intervention at the time you pull it into a progress note – once the intervention is selected from the Client Plan, it may not be edited and you must start over.  Do not save the service until you have verified the correct intervention/service code.

3.    Double check the server, service indicators, and assignment.  Do not save the service until you have verified the correct server, service indicators and assignment.

4.    Double check the content of the progress note – make sure it supports the intervention and service entry.  Do not save or final approve the note until you have verified all the service entry information and the content of the note.  Only final approve when you are certain the note is complete.

What blocks a note from being voided?

            If a service attached to the note has been claimed to the state:

The program holds the request to void until processed by the state (paid or denied) – further instructions to follow with 5010 implementation.

NOTE:  Do not remove or delete a service attached to a progress note unless you instructed to do so.  (if you delete a service from a final approved progress note, the system will not allow you to close the progress note without a service attached to it.  Please stop and contact the Help Desk for assistance.  Making the wrong choice in an attempt to correct the service or note can cause further complications that will delay or prevent the note and service from being corrected.)

 

 

Tesra Widmayer, Research Specialist
Mental Health Services - QI Unit
County of San Diego
(619)584-5026 (Phone)
(619) 584-5018 (Fax)

 

 

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