As an EHR provider, ShareNote Community is responsible for providing tools that accurately capture events related to the delivery and documentation of care in the most accurate way possible to ensure that the data we store and report on is accurate and valid. In this way, we provide tools that all providers can depend on to ensure that their compliant practices are accurately captured and reflected in the system. Providers have complete discretion in how they use tools and develop processes that best fit their practice, and they need to know that the data is true and correct.
Related Article and Video: Review, Lock, Sign, & Modify Notes Workflow; Review, Lock, Sign, & Modify Notes Workflow: Video
Best Practices
Although Providers have complete discretion in how they use tools and develop processes that best fit their practice, ShareNote Community recommends the following Best Practices when dealing with your BIRP and PIE Notes.
- It is recommended that you start your Note process for your agency in the Note Preferences.
- You can choose to allow all staff to lock and sign Notes, or select certain staff members in your agency to lock and sign Notes.
Staff should create, lock, and sign Notes at the same time. Please note that ShareNote Community records the date and time the Note was created as the same date and time the Note was submitted (within that minute). Therefor the Note History will show the time and date that the Note was created as the same date and time that the Note was submitted. This is also true if you submit multiple Notes at once.
Note Functionality
The below information illustrates how BIRP and PIE Notes look and function within ShareNote Community.
Signature Date and Time Stamps
The signature date and time stamp defaults to the current date and time a staff member applies their signature PIN to a Note.
Important: The ShareNote software considers Note creation to be at the time of submission.
Modifications to a Locked Note
If a Note has been locked, and a Supervisor has indicated that modifications need to be made, the Note must be unlocked in order to apply the needed modifications.
The unlocking of the Note will be captured in the Note History, and the Note author will be asked to document what is being modified and the reason for doing so. The reason for the modification will also be captured in the Note History.
Trashing a Note
Should a Note need to be deleted (trashed), the Note author will need to provide a reason for trashing the Note, and that reason will be captured in the Note History.
Note: Location Users and Lead Counselors do not have the ability to Trash Notes.
Note History
The Note history tells the story of a Note and captures all actions taken to the Note. Here are some scenarios that will be captured in your Note History.
Notes Automatically Saved as a Draft
In the event that you do not finish a Note and submit it in one sitting, your Note will automatically be saved as a draft. However, when you revisit that Note to sign and submit it, the Note History and the Note will state that it was created and submitted at the exact moment the staff member hits the Submit button, not the date and time that the staff initially created the Note.