Creating, Editing, and Deleting Case Notes

Case Notes can be created for an individual client or for a group of clients who attend a group activity.  Individual client Case Notes can be accessed from the following pages: Client, Admission, Program, Activity Log; while Group Notes can be accessed from the Group Attendance page in the Activity Log.  Case Notes created for clients who are linked to an admission and registered to a program can be accessed from all Case Note access points. Case Notes linked to Entry Services can only be created from the Activity Log.  Catalyst users must have appropriate Case Note privileges, along with program privileges to be able to create, edit, delete, view Case Notes.

Below is the Create Note screen in the Case Notes module.  This screen applies to all Case Notes with the exception of Group Case Notes.  Group notes contain a listing of the group members at the top of the note, and the Admission, and Program are not shown.  

Depending where Case Notes is accessed from, select fields will be pre-populated and not editable for business rules purposes, see below for details.

Creating a Case Note for Entry Services (No Open Admission)

Case Notes for Entry Services can be added for clients who do not have an open admission to the agency.  They are accessed through the Activity Log after the Pre-Entry Service information has been entered. 

The conditions that apply for Case Notes linked to registered clients apply to Case Notes linked to Entry Service. However there are additional conditions and exceptions that apply to Entry Services.

Additional Conditions:

• Case Notes for Entry Services can only be created for clients that do not have an open admission
• The Activity Type must be Pre-Entry Services
• The Activity Status must be “Occurred”
• Once created the Case Note can be edited from any access point
• The only information that can be edited from the note header is the “Author”
• Exception: There is one exception; Case Notes CANNOT be added for Anonymous clients

Creating a Case Note for a Client With an Admission

Adding a Case Note for a client with an admission can be done from the Admission Information, Program Information, and Activity Log - Appointment screens by clicking the Case Notes button.  The Case Note page displayed is the same for these access points, except there are added business rules when accessing Case Notes from the Individual Appointment in the Activity Log, as outlined below.

• An appointment must be created in the Activity Log and indicated as "Occurred" before the 'Save and go to Case Notes' button can be accessed.
• The program to be associated with the note must be chosen.

Per the table above, Note Date, Admission, and Program fields will be prepopulated according the screen the Case Note is accessed from.  Below is an example of a Case Note accessed from the Activity Log screen.

Creating a Case Note for Group Attendance

Case Notes may be added for all clients of a particular group.  The module is accessed through the Group Attendance List.  Once the attendance has been completed for the group members, click on Save and Go To Case Notes.  The Case Notes page will displayed will be slightly different from that of an individual case note.

• There is no Admission field or Program field as these may vary by client.
• The ClientID shown will be 0.

Important notes regarding Group Appointment Case Notes:

• Group Appointment Case Notes pertain to all the members of the group
• The purpose of group notes is to enable users to enter generalized notes about the group.
• No unique or personal client information should be added to these notes as the note will be added to each of the participants case note.
• If the clinician wants to add a specific note for a client in addition to the group note, the clinician can create an individual note for that client by accessing the chart/file for the client and adding a note.
• The group note feature is such that a group note is created for multiple clients/patients. A copy of this note will be filed on the electronic health record of each of the clients in the group attendance list.
• The Group Attendance Notes will not revert to generic individual or generic group notes.
• The Note Date (and Time) cannot be changed. It will not be possible to revert to regular client note (i.e. all fields become selectable) mode by clicking Clear Note from within the Group Case Notes.

General Notes for Creating Case Notes:

• In general, once the first individual appointment note has been added, the option is available to revert to regular client note (i.e. all fields become selectable) mode by clicking Clear Note. This means that Note Date, Admission, Program will be once again be selectable in preparation to adding a new note.
• If a second note for the same program is required, click the Reset to Default Values and Create New Note button at the bottom of the screen.  This will pre-fill the fields with the admission/program information once again.
• Attachments can be uploaded to a Case Note by clicking the Upload Attachment button.
• All mandatory fields are marked with a red asterisk.
• A note must have at least text content or an attachment; if both are missed an error message will appear on page.

Editing Case Notes

The Edit Note option will allow the user to edit some or all of the information in the Case Note.  There is a default window of opportunity to edit notes set at 48 hours after the system entry date and time. 

1. From the Notes History tab, locate the note to be edited.
2. Click on the red arrow to expand the note options. 
3. Click on the Edit Note button to access the original note screen to make the necessary changes.
4. Click Save Edited Note once the changes are complete.

Editing the Note Date of a Case Note

There are two date associated with each note:

1. Note Date - the date of the appointment may be edited within the 48 hour window after the system entry date and time.
2. Entered on Date - the date set by the computer system at the time and date of inputting the information.  This date is not editable.

Editing a Case Note After the Edit Window Period

If the 48 hour window has passed and an error requires correction, the window can be temporarily extended for the edits to be made.  To extend the window of time:

1. Go to Admin > Administration > Agency Preferences > Case Notes > Time period in hours to edit a Case Note after its creation. Add time period needed to be able to edit note.
2. Access the note and make the edit.
3. Once the required edits are complete, return to Agency Preferences and reset the time period for editing.

Adding a Sub-Note

Once the grace period to edit a note has passed, an Add Sub-note option becomes available in place of the Edit option. 

1. Click on Add Sub-note for the corresponding case note to access the Create Note screen.
   
   
   
   
2. Once in the Create Note screen, add the note.
3. Click Save Sub-note.
4. The Sub-note will appear under the main note.
   
   
   

Deleting Case Notes

Case Notes may be deleted by:

1. From the Notes History tab, locate the note to be edited.
2. Click on the red arrow to expand the note options. 
3. Click on the Edit Note button to access the original note.
   
   
   
   
4. Click Delete Note Panel and "choose a reason to delete this note..." from the drop down menu.
5. Click the Delete Note button to the right of the drop down menu that appears.

Reasons for Deletion include:

• Wrong Entry - the case note has been entered to the wrong Catalyst client file.
• Client Request - the client has requested that the agency remove the electronic case note from their file.
• Clinical Reason During Supervision - an agreement between author of note and clinical supervisor/agency Director, that the electronic note should not be part of the client’s file.

Audit Log 

Each time a user accesses the Case Notes module for a client, views, or performs any actions (creates/updates/deletes/expands a case note), a record is stored in the audit log to track these actions.

• Deletions are recorded in the “Audit Log History” of Catalyst.
• The Case Note will not be kept, but a fact that the note was deleted is kept.

Related content

• Page:
  Case Notes - Getting Started
• Page:
  How to delete old staff members from the Case Notes Author list
• Page:
  User Privileges for Case Notes
• Page:
  Privacy in Case Notes
• Page:
  Creating, Editing, and Deleting Case Notes
• Page:
  Creating, Deleting and Using a Template in Case Notes