In TechCare®, you can use Group Notes to write one general note about all patients who participated in a group session and efficiently apply that note to multiple patients. Additionally, you can also write individualized notes for each patient if you need to have more patient-specific documentation. To access Group Notes, click the Group Management option from the Global Menu, then select Group Notes.
The system displays the Clinical Monitoring Protocols screen. You must first choose a Group Note Type (1) from the dropdown menu. The system displays a list of patients that are in the group you selected.
To add a new patient to a group, click the Add Patient (2) button at the top of the screen. Search for an individual patient and click Find. Once you have found the patient, click Admit to add them to the group.
If you need to remove a patient from a group for any reason you can click the Discharge button for the patient and then enter a discharge note to properly dismiss them from the group. Once you click Add Note, the patient will be discharged from the group and removed from the Clinical Monitoring Protocols queue.
Group Note Documentation
To document on the entire group of patients, first select the Group Type from the dropdown list, then click the Group Documentation button on the Clinical Monitoring Protocols screen.
The system displays the Group Note screen.
Enter information in the following required fields:
- Date of Group – Enter the date the group encounter occurred in this field. The default date is today’s date.
- Practitioner – Enter the name of the practitioner who conducted the session.
- Group Type – This field displays the specialized Group Type you originally selected from the Clinical Monitoring Protocols screen.
- Attendance – You can use the check boxes beside the individual group members to include or exclude them from the group note. If a patient enrolled in the Group was absent from that session, or you want to not apply the Note to their patient record for any reason, simply deselect their name before you click the Add Note (7) button.
- Group Name – Enter the specialized name of the group (if applicable) in this field.
- Note – Enter all comments in this field regarding the group session.
Individual Note Documentation
You can also add an individual note for a specific patient using the Add Note option from the Action menu beside the patient. Common reasons you may need to make individual notes include properly documenting a patient’s absence from group, noteworthy information the clinician observed during a group session, general observations about appearance, mood, and many other patient specific items.
Enter information in the following fields:
- Practitioner – Enter the name of the practitioner who conducted the session.
- Group Name – Enter the specialized name of the group (if applicable) in this field.
- Note – Enter all comments in this field regarding the group session.
Once you have entered all information for the patient, click Add Note.