Add Session Note from Task List

Session Notes that added from the Task List will be automatically attached to the Appointment. Once a Note is added, you can view it from the Client's Notes tab.

Create Note

1. Click the Task List icon from the menu on the left.

   

   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
    
2. All Appointments that need a Note will display.

   

   
   
   
   
   
   
   
   
   
   
   
   
    
3. Locate desired Appointment and click Create Note or Copy & Create Note.

   

   
   
   
   
   
   
   
   
   
    
4. Select Therapy or Collaborative.
   • Therapy - Used for all billable Notes. i.e. Session Notes.
   • Collaborative - Used for NON-billable Notes.

     

     
     
     
     
     
     
     
     
     
     
     
     
      

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Complete Note

Start and End Date/Time, Service Code, Location and Client Diagnosis are all required to complete a Note. If you need to leave a Note to finish later, click Save and access it later from your Pending Notes.

1. Select Appointment Details.

   NOTE: Start and End Date/Time and Location default from Appointment.

2. Enter Mental Status.
3. Enter Risk Assessment.
4. Enter any Current Medications or Pharmacological History.

   NOTE: Information entered here will populate in future Notes so you can just make updates in the future.

5. Ensure a Diagnosis is entered. This defaults from Client Clinical Information tab.
6. Enter Clinical Information (SOAP - Subjective, Objective, Assessment, Plan).
7. Click Save Note. The Note will verify to ensure that all required fields are complete.
8. If there are any errors, fix the required fields.
9. Click Sign Note to complete Note.

   

   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
    

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