Session Note Screen

CILe - Client Information Ledger

What is on the Session Note screen?

The Session Note screen allows you to document the results of your session, what kind of session it was (individual, family, etc,) the fee and copay, and will automatically prepare the electronic claim for submission.

The Session Note screen

Click on any field to jump to the explanation of that field. Click the arrow to return to the screen image.

The following are descriptions of each element on the screen:

1) Session Notes	Allows a quick and convenient way to document the session and automatically produce the electronic claim from client and insurance information previously entered.
2) Name	The name of the client as entered into the "Display Name" field on the Fiscal Face Sheet.
3) Age	The age of the client as computed by using their birthdate entered on the Fiscal Face Sheet. Given in tenths of the year so you can quickly see if the client has a birthday coming up soon.
4) Validate Session Note	Click this button to see if everything you need is entered into CILe for the electronic claim to be accurately created.
5) Therapist	The name of the person signed into CILe when the session note is created. It may be the therapist, or if there is an Admin person, it will be them. It cannot be changed once the note is created.
6) Session Date	The date of the actual session with the client. It defaults to the date the note is created, but it can be changed by clicking the "Chg Incorrect Date" button.
7) Chg Incorrect Date button	Let's you change the "Session Date" if you are writing the session note on a day other than the one on which the session took place. If you click this button, two small arrows will appear. You can either type the correct date directly into the Session Date field, or you can use the arrows to change the date one day at a time.
8) Session Note	The text of the session note. There is no format or required information. If you would rather do your session note in Microsoft Word, by hand, or any other means, then simply put "See file" or some other indicator telling the reader where to go for details of the session. Important Feature: If you put the word "Note" as the first word of the text of the note, CILe interprets that as "I'm not done with this note yet, so don't let me lose track of it." (That's what the "Finish Note Later" button does.) It will then show up on the "Missing Session Notes" listing so you will remember to get back to it and finish it. This is particularly convenient if you want to go ahead and submit the electronic claim but want to get to the text later. I will often put cryptic comments in here so I can later remember the content of the session and then get back to it when I can flush it out better.
9) Printed Checkbox	You are not required by CILe to print the session notes, but if you decide you want to so you can put them in the client's paper file, then this checkbox will tell you if the note has been printed or not. You can either print it when you create it by printing the "Print This Note" button, or you can easily print many notes in bulk by going to the "Therapy" menu and selecting "Print Unprinted Note" off of the menu. If you know you won't ever want to print this particular note, then you can check this box, and if you ever do print "all" notes from the Therapy menu, this note will be skipped.
10) Add New Note button	When you first come into the "Session Notes" screen, you will be looking at the most recent note you've written. Click this button to create a new blank note.
11) Finish Note Later button	See the "Important Feature" note with the "Session Note" explanation above. This button performs that function.
12) Print This Note button	Immediately prints this button to your default printer regardless of whether or not the "Printed" checkbox is checked. If the note prints successfully, then the "Printed" checkbox will be checked. You can uncheck it again if you want this note to be picked up when you do the bulk printing from the Therapy menu.
13) Location	Just a pull-down menu allowing you to document exactly where this particular session or contact took place. It may be at your office, on the phone, or at another off-site location. If it is off-site, then you would document in the note itself exactly where it took place.
14) Resubmit Claim	If you need to resubmit this claim again, check this box. This may happen because your original claim never made it to the insurance company, or they denied it for some reason that you have now resolved, or whatever.
15) Use Primary Insurance	Tells CILe to use the client's primary insurance company as specified on their Fiscal Face Sheet to submit this claim. If you check this and the "Use Secondary Insurance" checkboxes, then CILe will create two e-claims, one for each insurance policy. When you create a new session note, it will automatically default to "Use Primary Insurance" but not "Use Secondary Insurance." You can manually change these defaults before you save the session note to specify which insurance company to use. To submit the claim at a later date, uncheck the checkbox and return to this session note to check them when you are ready.
16) Use Secondary Insurance	Tells CILe to use the client's secondary insurance company as specified on their Fiscal Face Sheet to submit this claim. If you check this and the "Use Primary Insurance" checkboxes, then CILe will create two e-claims, one for each insurance policy. When you create a new session note, it will automatically default to "Use Primary Insurance" but not "Use Secondary Insurance." You can manually change these defaults before you save the session note to specify which insurance company to use. To submit the claim at a later date, leave the checkbox unchecked and return to this session note to check it when you are ready.
17) Next Session	This is a free-form text box allowing you to document a quick note regarding the next session while it is fresh on your mind. I use it to document things like, "Next week," Two weeks," "on vacation next week" or the like. You can use it any way you'd like. Then, whatever you put here will show up on the "Next Session Note from Previous" field on the next schedule. (Note: CILe will skip the 'most recent' session note if it is a "Group" session note, and jump to the most recent note where the client was the focus of the session rather than an entire group.) The logic behind this field: If you are using the "Standing Schedule" feature of CILe, then this client will be populated onto the schedule without regard to what they verbally informed you about any particular session. I added this field so I could avoid sitting there and waiting for a client to come because I'd forgotten that they told me they wouldn't be here this week.
18) Homework	Allows you to quickly document the client's homework assigned during this session. Then, when you click the "Prior Notes" button on the schedule screen, the homework assignment will show up as a separate item, allowing you to quickly see what it was you had asked the client to do in the last session without having to read the entire note.
19) Visit	A pull-down menu allowing you to document whether the client showed up or not. If you select anything other than "Kept," a session note will not be created. If you select "cancelled by client" or "cancelled by clinic" and have not yet typed anything into the session note itself, then the system will populate the session note with a standard note. If you select, "No Show," then CILe will ask you if you want to produce a standard letter to mail to the client informing them that they've missed an appointment, and charging them the no-show fee you specified in your "Employee Information" screen.
20) Service	Allows you to specify what kind of service you performed for this client. Type the first letter of the service, and if it is first in the sort order, it will automatically pop up. This field will be used to populate the CPT code field (90801, 90806, etc) on the claim form. You have complete control over what gets displayed on this pull-down, so you can tailor it to your own business. If you want to change it, go to the Administrative menu and select "Service Codes." You can add new service codes by scrolling to the bottom, or you can add or remove service codes from the pull-down by checking or unchecking the "Display on pull-down" box. You can also change the order in which they show up on the pull-down with the "Sort Order" field.
21) Session Time	This is the time that the client is on the schedule for this session. This is an important field because you may see the client more than once on any particular day (say, for an individual session and then they attend a group later in the day.) CILe needs to keep these two sessions clearly identified in the data tables, so the combination of the date and time are used. This time must be the same as is on the schedule, or the claim will not be produced. CILe will automatically populate this field when you tab into it if it is blank, but if you have the client scheduled for two sessions (ind and group), then you may need to manually correct this for one of the two sessions.
22) Dx Code	This is the diagnosis that will appear on the claim for this particular date of service. CILe will automatically populate it from the client's Diagnosis screen that you filled out when you did their original intake. If you have not done that yet, then it will automatically populate it with "None" when you tab into that field. CILe will not allow the claim to be created if this field says "None" because the insurance company won't pay it. This is one of the validation criteria.
23) Fee	This is your normal fee for a session. The insurance company will reduce what they pay you to their allowable fee, but I would suggest using this box to document your actual fee rather than the allowable fee. This value has to be more than zero for the claim to be created.
24) Client Portion Owed	This allows you to document the amount of money the client owes you for this session. This goes into the CILe accounting report so you can keep track of what the client actually owes you. It could be a copay, a co-insurance, or if the client is self-pay, the fee you are charging them. This value is automatically populated from the "Client Copay" screen you access from the Fiscal Face Sheet or the Client pop-up menu.
25) Client Portion Waived	This allows you to document any waivers of the "Client Portion Owed." For instance, if their normal copay is $20, but you know they are destitute poor and they can't afford more than $5 a week and you want to work with them, then go ahead and document the $20, but give them a $15 waiver so you can keep track of your decision. I also use this for the first "no-show" visit where I document the no-show fee, but I give them a 'grace' no-show for the first time. I "charge" them the standard no-show fee, but then I waive it for the first session. This will then be printed that way on any accounting reports they get so they can see that that grace was given.
26) Amt Paid	This documents the amount of money the client actually gave you that day. This is the "money in hand" amount. This will also be used to feed into the "Deposits to be done" report so you can keep track of what you have to take to the bank (your actual deposit slip) and reconcile it with what you've actually documented in CILe as having been received. If they don't match, then you've either missed documenting something in CILe or you've missed putting something on the deposit slip. I use this as an invaluable double-check so I never have that anxiety of whether a client paid me or not.
27) Mode	Allows you to document how the client paid you. I will put things like "Cash," "Cash ($20 bill)", "Check," "Check 4234" to document the check number. that way, if I find I'm missing something, I have an easier way of tracking it down. It has been a tremendous time-saver.
28) Prim EClaim ID	This is the most recent primary insurance company claim that this session was submitted on. If you have submitted this date of service more than once, then the most recent one will appear here, and any prior ones will appear in the Eclaim Hx (history) field. You can then use this number to go to the Fiscal Menu and select "Show Electronic Claims Submitted."
29) Prim submitted	Shows you the date that this electronic claim was generated by CILe. This is not necessarily the date it was transmitted to the clearinghouse for disbursal to the insurance company.
30) EClaim ID Sec	This is the most recent secondary insurance company claim that this session was submitted on. If you have submitted this date of service more than once, then the most recent one will appear here, and any prior ones will appear in the Eclaim Hx (history) field. You can then use this number to go to the Fiscal Menu and select "Show Electronic Claims Submitted."
30) Sec submitted	Shows you the date that this electronic claim was generated by CILe using the secondary insurance information. This is not necessarily the date it was transmitted to the clearinghouse for disbursal to the insurance company.
30) Primary Transferred Date	This is the date the Microsoft Excel file was created by CILe containing this claim. Whether or not the file was actually uploaded to the clearinghouse is external to CILe and cannot be tracked. It is simply the create date of the file, and assumes that you would have uploaded it on that same day. (Hint: I change the name of the created file to begin with the letter "z" when I have successfully uploaded it. That way, I have a bit of a flag that something hasn't been uploaded (say, if the internet is down or I don't have access or whatever.)
30) EClaim Hx	This will show you if you have created claims for this date of service on any other claims besides the latest one.
30) Invoice Nbr	This shows you an "invoice" number if you choose to submit a claim for this client on paper rather than electronically. This is why it is important to "produce" the HCFA 1500 form using CILe even if you decide to hand-write the entire form. With this number, you will then be able to track the payments with CILe on the "Insurance Payment Maintenance" screen.
30) Jump to Date button	Once you have more than a handfull of session notes for a client, it's time-consuming to arrow through them all to find a particular one. Type in the date of the session note you want to look at and click the "Jump to Date" button and the desired note will be displayed.
30) Reminder	This allows you to make a quick note of some action you need to take on behalf of this client as determined during this session. You can then get a list of all of the "Reminders" you have for all clients off of the Therapy menu. This is a kind of "client specific" to-do list. When you have accomplished your reminder, then you can uncheck the "Active" box on that screen and it won't show up any more, but will always be associated with that session note.
30) Session Note Sort	This allows you to change the sort order of the session notes. You may want to do that if you have documented more than one contact on a specific day, and for some reason, you would rather have them show up in a particular order in the system. For instance, if you had a telephone contact with a client early in the day, but didn't get around to documenting it until after your sessionn with them, you can change the time portion of this field to force the system to reflect the accuracy of the order of the contacts.
30) Navigation Arrows	The standard computer navigation buttons. The left-facing double-button takes you to the very first session note and the right-facing double-button takes you to the very last one. The single-buttons jump one note at a time.

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