Session Logging

SESSION LOGGING

How to create/post a session note

Please note a SESSION needs to be logged each week so the notes will read like an electronic book. Only one session can be posted weekly unless you are doing a makup which requires a missed session to be logged first.

***ONLY 1 ATTENDED session can occur per week (as the plan states)

Staff should be logging a session each week: MISSED or ATTENDED

Definitions of SESSIONS:

ATTENDED SESSION - this is your regular session note during your scheduled time."Attended" sessions should not have missed session codes on them.

Rescheduled Session – this means the session was rescheduled to another day in the same week. Complete a regular ATTENDED SESSION note and document the date difference in the body of the note.

MISSED SESSION (canceled) – this means the session for the week has been completely canceled and you are not seeing the child at all for the rest of the week (this is for canceled or no-show)

MAKEUP SESSION-SCHEDULED MISSED SESSION – The family is leaving for an extended amount of time or knows there will be a break in services for several weeks. A MISSED SESSION needs to be logged in order to create a MAKEUP SESSION note. This can occur the following week after the missed session and should be coded the same way as the missed log.

This is where therapists can view the details of historical sessions, submit new ones, and mass download session notes. How can you check to ensure all sessions are logged for billing/payroll purposes?-See Video

Desktop EMR Options:

Submitting Paper Session Notes

***CFY ONLY-Please note SUPERVISEES MUST SAVE ALL NOTES AS A DRAFT FOR SIGNATURE BY A SUPERVISOR. IF A NOTE IS NOT SAVED AS A DRAFT IT WILL HAVE TO BE DOWNLOADED AND HAND SIGNED.

**The note will be a PDF and you can only edit it with a PDF writer or print, make a correction and re-upload it using the submitting a paper session note directions.

MISSED and MAKEUP Session Logging

In order to log a session as a MAKEUP, there has to have been a MISSED document in the record as the make-up session needs to correspond to the date of the (documented) missed session.This can occur the following week after the missed session. The MAKEUP note must be coded the same way as the missed session.

Example:

Entry 1 is MISSED session logged and Entry 2 is MAKEUP session

How do I log a MISSED Session and document on the communication log to save time while documenting?

Missed Session and Communication Log-Video

1- Click Session Logging

Attendance Status-select MISSED in the dropdown

Session Note Reminders:

Submit your session notes daily. If for some reason you did not submit all your session notes throughout the week, they must ALL be submitted by 6 pm on the 15th and the last day of the month to count toward that week’s payroll. Any submissions after that will be pushed to the following payroll run.
If there are 2 goals, please poulate one TARGET for each goal.
Once a session note has been produced, please check to make sure the "Geolocation" information is listed under signatures. You may see "User denied Geolocation". In that case, please check the settings on your device to allow your geolocation to be captured.
If you REQUEST a SIGNATURE from a family during a TI session from your desktop PS EMR, please stay on until they receive the link in their email and sign it with you virtually present to make sure it is submitted. This will allow the session note to be submitted properly for billing/payroll without a delay.

-Note: The secure link is HIPAA-protected and parents need to access the most recent link for it to work.

App Option to Post a Session Note:

**This is what most people use.

Posting a Session Note Using the App

Posting a Note:

In the bottom right corner, select the Blue +.
Fill in all text boxes. The app will not allow you to submit with empty text boxes.
Collect signatures from caregiver/parent present. You MUST DOUBLE TAP the box for it to become active to sign for both parent and providers.*Once a signature is saved, the date and time for the session CAN NOT be edited.* If you need to make a correction, you need to erase signatures and get them again.
If you need to leave a session before finishing a note, you can exit the note and it will save drafts.
Once a note is completed, select submit following the parent signature page.
Return to the child’s name under Current, click the 3 dots on the upper right hand corner. Download PDF and send to the family via email or text at their request.
It is your responsibility to make sure all session notes are posted for billing by 11:59 pm on Sunday to be eligible for payroll. The admin can NOT see pending notes.
Berks providers using the mobile App will need to manually enter their BSU # at the first session. After that, it will carry over to subsequent notes.
The top left of the app shows 3 lines. Selecting these lines will show you Assignments and My Notes. My notes shows submitted notes, Draft notes, and Failed notes. This is a convenient place to see any notes you may have at the end of the week which were or were not submitted.
You can submit a MISSED session on the app, Mobile Session note must include :

Missed Visit Date
Begin Time-(Time session was supposed to occur)
End Time
Attendance Status- MISSED
Reason for Missed

**If you no not have this ability, update your app in the App Store.

If you do not see a child's name or a session note is stuck in the Que, log out of the app and log back in.

**The note will be a PDF and you can only edit it with a PDF writer or print, make a correction and re-upload it on the desktop EMR using the submitting a paper session note directions.

Last Session- You will have 2 choices:
1. Use the app and write that it is the last session in the first sentence in the body of the note and write the date of the last session in the date/time of next session at the bottom.
2. Write the last session note using your computer to log the session.

How to share a session note with a caregiver from the app

Here are some general instructions from an iPhone:

Complete the note

Go back into the child's name, on the top right click "Notes"

Find the date of the session you want

On the right you will see three dots, click them

Choose "Download PDF"

The note will appear on your screen

Click the box with an arrow on the bottom right of your screen

You can then email or text the session note to the caregiver

Click here for a brief video demonstrating this process

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