The system is designed to help you organize, and keep secure, the client electronic health record (EHR). Accessed from the Client Details page client case and progress note forms allow you to capture clinical information for a client.
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Client Cases
REQUIRED PERMISSIONS: Access is determined by Client assignment and User Permissions.
A Case is a collection (like a file folder) of notes and clinical information for a client. Cases provide a higher level of privacy for client information such as Initial Assessments, Diagnostic Codes, Progress Notes, Treatment Plans, etc., keeping this information separate from a client's basic record.
Sometimes a client can have multiple cases, for example, if they have individual appointments and are a part of a group, there would be a case for their individual session notes and another case for their group session notes.
Dynamic Case Forms can be created and used to capture specific case information and may include dynamic elements pulled from the system. Dynamic elements are:
- Client Full Name
- Client Email
- Client Mobile Phone Number
- Client Date of Birth
Dynamic Case Forms can also be copied to Intake Forms and be shared, via the Clinical Documents tab, to the client through the Client Portal.
All cases and individual case info are accessed from a tab on the client notes page.
NOTE: Only Staff assigned to a client may access Case Notes.
Progress Notes
REQUIRED PERMISSIONS: Administrators and assigned therapists can view and add Progress Notes to the case.
Progress Notes are designed to capture session info as well as treatment updates for each session and are linked to client appointments. A Standard Note and SOAP Note are included in the system.
Custom Dynamic Progress Note forms can be created for specific types of appointments or uses and be set as a default for the system or for specific Therapists.
When Wiley Practice Planners are used, information from the planner will be automatically pulled into a Dynamic Progress Note form.
Staff Permissions and Client Access
As stated above, staff access to a case is determined by client assignment and their user permissions. Because cases have a higher level of privacy, staff members must be assigned to clients AND also be assigned to the case.
By default staff members can access Client Details unless, as a therapist, you have selected that they can only view assigned clients permission.
| If this permission is checked, the staff member won't see ANY clients in the system unless they are manually assigned to a client. They could search a client name and nothing would display if they aren't assigned to that client. If this permission were unchecked, the staff member could search for any client and see if they are a client. Related Article: Assign Staff Permission |
- In order to create a Client Case and/or view a client's Clinical information, Staff Member must be assigned to the Client.
- Once a staff member is assigned to a Client they can create a case. If you create a case, you will automatically be assigned to that case. Being assigned to a case means that you can input and view Clinical Information such as Progress Notes, Treatment Plans, etc.
- If someone else creates the client's case, you can be assigned to the case by the staff member who created it or an administrator.
Case & Notes FAQs
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Are Signatures required for my notes? Can I require signatures?
The system does not require you to sign documents and there is not a way to make signatures required. You may implement your own business standard operating procedure that requires signatures. Also, some payers you submit to may require you to sign your notes or Treatment Plans.NOTE: Run the Notes History report when all of the therapist's progress notes are signed. Running this report when there are unsigned progress notes can cause an error and system timeout before the report can be completed.
- Can I import my own Note Template?
At this time existing Note Templates can’t be imported into the system. However, you can create custom forms to create your own forms and collect any supplemental information our forms do not collect for you.
- Can I edit the Progress Note Template?
You can remove all fields or sections that are not applicable to you. This is an Organization-wide setting and cannot be customized by the therapist.
- Can I add my own fields to the Progress Note template?
Yes, you can add custom fields to your progress notes.
- Are the system’s notes Medicare compliant?
Medicare compliance is guided by state Medicare/Medicaid rules. There is no universal mental health note format, or more specifically, no format that is universally accepted by all insurers. We have attempted to create a note format that is acceptable to the majority of providers and to the insurers they work with.
If you need to comply with a particular policy based on your region and our progress note template does not meet your needs, you are welcome to design your own note using the custom form builder or reach out to our support team.