Appointment Documentation Quick Start

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Initial Assessment

User Role: Therapist or Admin assigned to Case 

Why: Completing the Initial Assessment first will ensure that the diagnostic code populates on other necessary documentation such as the Treatment Plan, Progress Note, Superbill, and Insurance Claims.

• 6.1 Click the Add Progress Note button
• 6.2 Click the Initial Assessment & Diagnostic Code tab
• 6.3 Click the Add Diagnosis button
• 6.4 Select a diagnosis from the list
• 6.5 Click Save

  

   

  

Related Articles:

• Initial Assessment & Diagnostic Codes
• Add Client Diagnosis

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Treatment Plan

User Role: Therapist or Admin assigned to the Case

Why: Completing the Treatment Plan will ensure that the Client Goals populate on other necessary documentation such as the Progress Note.

• 6.6 Click the Treatment Plans tab
• 6.7 Click the Add Treatment Plan button
• 6.8 Click the Add Goal button
• 6.10 Enter the Goal
• 6.11 Enter the Objective
• 6.12 Select the Intervention
• 6.13 Click Save (to save goals)
• 6.14 Click Save (to save the Treatment Plan)

  

  

   

  

Related Articles:

• Add or Edit a Treatment Plan

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Progress Note

User Role: Therapist or Admin assigned to Case

Why: Creating a Progress Note will ensure that the Appointment, Service Type, Diagnosis, and Goals are all connected to complete the Client EHR. This will also allow for proper billing.

• 6.15 Click the Progress Note tab
• 6.16 Click the Add+ Progress Note button
• 6.17 Select the Note Type template
• 6.18 Click the Create Note button
• 6.19 Select the appointment from the list
• 6.20 Click Save

  

  

   

  

Related Articles:

• Create a Progress Note

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