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CSU Documentation in Neo
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| This is a guide for entering progress notes during your shift. As of 12:01 on 12/27/24, you are no longer able to enter a shift note. All documentation will need to be completed using the following steps. |
Where To Document |
| There have been some changes in Neo. Crisis Stabilization Unit(CSU) has been added as its own program. You will now be completing your daily/shift documentation from a different tab in Neo. Previously, you were accessing a shift note while in the Crisis tab. Here are the steps for how to document beginning on 12/27/24 at 12:01 am: |
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You will then see the following on your Dashboard - this is where daily documentation will be entered.  |
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From this screen you can navigate between Ticonic Street and Bangor Lane depending on which program you are working at. By using the Program Name dropdown menu, you can select which facility you are at. You can also filter by Date if you have notes to enter from a previous shift.  |
Any resident admitted to the facility will show up under the search/program name section. |
| The following example documentation is for Neo test client, Alex R. Archer. |
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Click the S (select).  |
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After selecting the S(Select), the note will pop up. Selecting a Short Term Goal will reveal a text field to document your interaction and input how much time was spent with the client.  |
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Selecting an Action Step will reveal a text field to document your interaction and input how much time was spent with the client.  |
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When done, hit the Save button to the right of Estimated Time.  |
Add any observations to the Observation/Personal Care box (this is typically a summary of ADLs and any medication passes that occurred during your shift.)
Click the Flag for Followup box if you want a reminder to follow up on something from your documentation. This is simply an alert for yourself if you wish to use it.
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Once you have completed your note, click Save at the bottom of the note. DO NOT CLICK SIGN! SELECTING SIGN CLOSES THE NOTE TO EVERYONE. This step is important because all staff will now be documenting from the same note and a supervisor will complete and sign the note the following day. |
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This is what the note will look like after you hit save. Your note is date and time stamped with your name and can be differentiated from other entries entered by other staff.  |
When To Document |
| It’s expected that all documentation will be completed by the end of your shift. When building your schedule, be sure to schedule in time for documentation. If you take time throughout your day to do documentation, you should have no problem completing your notes. In the event that you have been away at appointments, or otherwise engaged with a client and you are unable to get your notes completed before shift report, attend shift report, let the supervisor (or on call) know that you will need to stay to finish your notes. Do not leave without finishing your documentation without speaking to your supervisor or on call. |
Personal Care/Observation Note |
| The P note should include tasks related to personal care; Personal hygiene, apartment cleaning and checks, medications, client whereabouts, health and safety, arranging of transportation, phone calls to providers, medical and psych appointments, changes in behaviors, and social activities. Also, any activities you are required to do for the client because they are unable would be in the P note because it isn’t showing any actual work by the client. If you have to cook or clean due to circumstances please note this here with what you observed and why it required you to complete the task for the client. Document any safety checks that you do for client (30 min checks, 15 min checks, 1 hour checks etc.) |
Provider Appointments |
| What is the appointment for? What did staff do to prepare for the appointment? What was the outcome of the appointment? |
Room Checks |
| When checking the client’s apartment for health and safety reasons, you may be looking for such things as are the lights working, lock's working; is the toilet clean and the floor is free of obstructions/tripping hazards? Are the counters and tables clean and free of clutter, is the trash overflowing? Do you observe any leaks in the sinks or any outdated food in the refrigerator? |
Client Hygiene |
| Overall assessment of the client’s personal hygiene, such as clean hair, showered, clean and appropriate clothing, any body odor, etc. |
Medications |
| If you are the CRMA on duty, you would document on basic observations about client presenting for medications, any refusals and PRNs. Med education should go in the R note because that is a skill set you are building with the client. |