Group Note

May 06, 2025 21:30

Overview

This video will be an overview of the navigation of the Group Note. Please keep in mind some sections like the "Encounter Type," may not be visable and or there for you to fill out. This will be dependant on if your company wanted this in the setup.

Getting Started

Please Note: Most pages and tabs are configurable within AxiomEHR. So these will look slightly different depending on how your company has set them up. Ex: There is an "All" and "Category" view.

All - Will make everything thing in the section show as one page.

Category - Will separate the sections out for you. For most of these we will.

You will first need to navigate to the Group Note page. You can do so via the search at the top or from your tab set.

Starting the Group Note

1. Make sure you are in the Group Note section

2. Group - This is where you will select the Group you are starting the note for. (Note - A group will need to be created for you by your companies dedicate Admin staff/Super Users)

3. Service Date - Select the date the group happened.

4. Lookup Patient - Select this to see the list of patients who are assigned to the chosen group.

Change Temporary Facilitator - This will populate a pop-up window that will allow you to temporarily change the facilitator.

5. This section will show all the patients who are signed up for the selected group. In this section you can do things like: add new patients, remove a patient, mark them as not present but they are still apart of the group, and get a break down of some common group over view items (Patient names, sessions attended, and amounts for the patients)

a. You can/will collect their signatures on this page if they have attended.

b. On the far right there is a "Status" column. This will give you options like: Present, Client No Show (Non-billable), Leaving Phone Message (Non-billable), and Expire.

6. Services - This is where you will select the Site you are working and the Service (Service Code) being provided

After selecting the service code, it will populate on the note and you can add information related to the code to it!

7. Start Time and End Time - This will be when the group session started and ended.

8. Minutes and Units - These auto populate based on the Start and End time. The Units reflect the Fee Schedule for the payor based on the service code selected.

9. POS - This will be where the service was provided.

10. Co-Facilitator - This will allow you to add additional facilitators in the event your group has more than just one, or maybe you are training someone.

11. Data - This is where you add data from your counseling or psychotherapy session. This could include things like, reason for the visit, client presentation/appearance, client mental status, client reports of current symptoms. or important events since the last session.

12. Action Plan - Given the observed data and your interpretation of it, where does treatment go from here? This section could include things like the date, time, and location of the next scheduled session, homework assigned to the client, referrals provided to the client, or additional steps related to the treatment that the client or clinician is expected to take.

Data and Action Plan will be applied to each of the notes being written. In the next section the "Assessment" will be patient specific.

13. Group Members - This is where you will see the patients "present" in the group you are filling out the note for.

14. Services - You can add a service here, in a more secular manner, in the event you provided additional services to one client specifically. Or if

15. Client Identified Need - This will be where you select the Identified Need per client. You will have options like, "Allow All Services" or other needs that are based on the clients Service Plan.

16. Assessment - This section is where you take the data from the first section and apply your clinical judgment to it. This could include things like: How the client is progressing, how the client’s status relates to their treatment goals, how the client responded, or changes to the client’s diagnosis

17. Save & Move To Next Unaltered - This will allow you to save the info added to the current client and move to the next client with no data from this page (Unaltered).

18. Completion Status - You will choose either Incomplete, Complete, Or Pend for Review. Then you can hit Next once all data is completed for all present clients.