Continued Care: Reviewing Documentation and Adding Review Signers

State regulations and staff credentials determine when review signatures are required. Some documents require a higher-level review to meet billing and compliance mandates, particularly when created by trainee therapists, case managers, or techs without the necessary credentials. Clinical directors, medical directors, or licensed therapists typically serve as reviewers. Once the document creator signs it, the document enters the ready for review status, shifting responsibility to the assigned reviewer. Reviewers use the Dashboard to filter documents, ensuring compliance, accuracy, and completeness.

Common Documentation Requiring Review Signatures

• Treatment Plans
• Progress Notes
• Biopsychosocial Evaluations
• ASAM Forms
• Discharge Documentation
• Initial Psych Evaluations
• Lab Results
• Medical Forms (e.g., H&P, Suicide Risk Assessments)

Kipu Features Available to Review Documentation

• Dashboard: View and manage documents requiring review signature.
• Chart✓: Set deadlines and track the completion of patient forms in ready for review status.
• Patient Portal: Obtain patients, guardians, and guarantor signatures when necessary.
• Refinement Requested:  Request revisions by sending documents back with comments.
• Notifications: Alert reviewers about documents needing attention.

Note: Reviewers receive notifications only when added through the Add Signer button, but this method is not recommended due to the risk of human error.

Best Practice Workflows Steps

Let's review the best practices steps in Kipu EMR to ensures compliance, reduces errors, and streamlines the review process for facility documentation.

1. Click + Add Form to the patient's chart.
2. Complete the form and sign using a PIN.
3. The document status updates to ready for review if the evaluation template is configured to require a review.
   • Best Practice: Configure documentation templates to require a signature instead of using the Add Signer function, which increases the risk of human error. If a review is not required in the template settings, the document status updates to Completed without needing a review signature.
4. Navigate to Dashboard, select the Current Census tab, and filter by Ready for Review status to locate forms requiring review.
5. Click Start Signing under each patient to review documentation individually. This opens the document for review.
   • Best Practice: To review multiple patient forms efficiently, click Start Signing in the top-right corner.
     
6. Navigate to Schedules and select Past Group Sessions to find the sessions pending review.
7. Review the group session notes and sign with a PIN.
8. Examine documents for completeness, accuracy, and compliance. Ensure all necessary information is included and provide feedback if corrections are needed.

Workflow 1: Refinement or Revisions Are Needed

 If refinements are needed, complete the following steps: 

1. In the desired evaluation form, click Add Comments/Print Preview button to enter the required changes.
2.  Highlight the desired text and click on the Comment icon.
3. Type the comment or correction related to the highlighted text and click Create.
   
4. Comments appear at the top right of the evaluation form.
5. Select the Needs Refinement status on the Dashboard to track pending refinements.
6. Complete the refinement requested documentation workflow.
7. Click Start Signing in the top-right corner to sign off on all pending documents. 
8. Alternatively, click Start Signing under each individual patient to review and sign their documents separately. 
9.  Use a PIN when signing documents to streamline the process. 

Best Practice: If the user is unable to complete the documentation during the session, use the refinement request documentation workflow to track outstanding documents.