The safety, continuity of care and coordination of interdisciplinary treatment for any Hillcrest student depend in part on the accurate and timely documentation of services provided to, and significant events in the student’s life. Effective case documentation also serves to support the student’s treatment plan and effective clinical decision-making, and it constitutes part of the legal record for that student.
Hillcrest utilizes many different forms of case documentation including the Progress Note, an important record written by staff who directly provide care and services to the student. All progress notes at HEC are in electronic form and are accessible through a secure privileging system assigned to clinical and administrative staff. Electronic progress notes are backed up and stored off site on a daily basis. They are periodically archived to DVD media on a yearly basis. Progress notes for, at least, the previous 24 months are always available in the online system.
It is commonly considered to be “best practice” for Progress Notes that, to the extent possible:
• They reflect the chronology or order of service and care events as they happen, and,
• They are written as soon as possible after the service or event, because the closer the documentation is recorded to the actual event, the more accurate and reliable the documentation tends to be.
It is Hillcrest’s policy that, whenever possible, the Progress Note will be entered into the student record on the day or the day following the provision of the service or the occurrence of the event. If circumstances prevent the entry by the end of the day following the provision of the service or the occurrence of the event, the entry is made as soon as possible after that day, and is classified as a late entry.
The following format and protocol are used when making a late entry.
• The current date and time are written in the left hand column.
• The entry begins: “Late entry for (date the service or event occurred)”, followed by the identification of the service or event. For example, “Late entry for 1/24/049. Weekly Individual Therapy x 45 minutes.”

Progress Notes – Time of Day In Progress Notes
Traditionally at Hillcrest we have required that the time of day at which a Progress Note is being written be included under the date of the PN in the left hand margin. However, in addition to sometimes causing confusion (i.e., is it the time the note is written or the time the service was provided?), we have determined that only HEC policy requires this inclusion of the time in the Progress Notes of all disciplines. It is apparently not required by any regulatory agency or accreditation body, and it is not commonly considered standard practice among behavioral health care providers.

Therefore, after consultation with other managers, we have determined that from this point forward, with the exception of Nursing PNs, it will not be necessary to enter the time of day under the date on a PN. Nurses will continue to note the time of day.