Residential Module - Staff Notes

Residential Module - Staff Notes



Getting There:

In the Residential Module staff will have daily notes where they can write the daily activities and monitoring of patients in Residential services.  Axiom offers two distinct notes for staff to input service notes in the Residential Module.  The Daily Staff Notes and the Nurse Daily Note.  The only difference between the two is that the Nurse note is for use by LPN or RN's. 




Once in the Residential Module click the switch to Grid View button



Grid view offers a table view of the module. There you will find an action drop down menu for each patient where you can find the Daily Staff Note.









 Daily Staff Note



  1. Note Date:  In this section you will be able to add the date of the note that will be added.
  2. Start Time: In this section you will be able to add the start time of the note.
  3. End Time: In this section you will be able to add the end time of the note.
  4. Residential Identified Needs: This drop down menu will allow you to input the identified needs of the patient in Residential. All identified needs options in this drop down menu come from the Service Plan.  See our Service Plan Article for further information on adding identified needs.
  5. Service Site: In this section you will be able to select the service site of the note.

  6. Assessment: This is a free text box where you can input Assessment information.
  7. Action Plan: This is a free text box that will allow you to input Action Plan information.
  8. Mental Status Exam: Depending on the type of service selected it a mental status exam may be required to be filled. If the mental status exam does not populate after selecting a service that indicates that it is not required.
  9. Improvements: This section allows you to select what improvement if any the patient has had. There is a comment box along with this section that allows the user to input any information in regards to the Improvement selection.
  10. Save Complete, Save Incomplete, Reset: This section allows you to save the note complete if it is finished, or you can save as a draft by saving incomplete. Or you can reset the entire note to clear all fields and restart. 

History


  1. History Table: This section will provide a view of all notes saved complete or incomplete. 
  2. Action: This drop down menu for the history table allows the user to view a note, print or edit an existing saved note. 


Nurse Daily Note



The Nurse Daily Note can be found in the same drop down menu as the Daily Staff Note.




  1. Note Date:  In this section you will be able to add the date of the note that will be added.
  2. Start Time: In this section you will be able to add the start time of the note.
  3. End Time: In this section you will be able to add the end time of the note.
  4. Service Site: In this section you will be able to select the service site of the note.
  5. Inpatient Daily Information: This section allows you to input Daily information on the patient being observed. 
  6. Mental Status Exam: this section is the daily mental status exam that is filled regarding the observed patient. Each box contains selections that will highlight once clicked on. Below the boxes there is a smaller empty free text box that allows you to input any additional information regarding the selection made. 
  7. Save Complete, Save Incomplete, Reset: This section allows you to save the note complete if it is finished, or you can save as a draft by saving incomplete. Or you can reset the entire note to clear all fields and restart. 

History


  1. History Table: This section will provide a view of all notes saved complete or incomplete. 
  2. Action: This drop down menu for the history table allows the user to view a note, print or edit an existing saved note. 



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