Continued Care: Manage Pending Documentation

Facilities must maintain updated and complete documentation within specified intervals to comply with state regulations. Users often encounter situations where evaluations, such as biopsychosocial, individual session notes, and group session notes, remain incomplete after they are started. Tracking and completing these documents is essential for compliance and billing. Incomplete documentation can stall treatment decisions and impact patient progress. Additionally, before discharging or transferring a patient’s chart between locations, users must review and sign off on all pending documentation.

Required Permissions: Therapists, super admins, records admins, and users with the Manage Group Sessions, or Review Group Session permissions added to their user profiles.

Best Practice Workflow Video

Best Practice Workflow Steps

Lets' review the best practice workflow to manage pending documentation. 

Workflow 1: Completing In Progress Documentation

1. Click on Dashboard then on the Current Census or Discharge Patients tab to view all patients with incomplete documentation.
2. Then click on the My Items subtab to display documentation assigned to you.
3. You can use additional filters to search by status and items created by you.
• Best Practice: Assign the care team during admission so that case managers, nurses, physicians, and therapists can filter their patients in the Dashboard.
4. Sign documentation using one of the following methods:
   • Click Start Signing in the top-right corner to sign off on all pending documents.
   • Click Start Signing under each individual patient to review and sign their documents separately.

• • Best Practice: Use a PIN when signing documents to streamline the process.

Workflow 2: Completing In Progress Group Sessions

This workflow ensures compliance, maintains accurate records, and prevents delays in patient care and billing.

1. Navigate to Schedules in the header and click on the Past Group Sessions tab.
2. Use the search bar to enter your name and filter the column headers by status (In Progress or Pending Review).
3. Open the notes and complete the documentation for each session.
4. Click on Add Group Signer if an additional group session leader needs to sign.
• Best Practice: Add all required signers before signing yourself to ensure proper workflow. The system sends a notification to the added group signer for review.
5. Click on Group Leader Sign Off & Submit. Then, sign the session using your PIN.