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How to add progress and psychotherapy notes

For every client appointment, you can add a progress note and a psychotherapy note from the Session Details page.

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Progress & psychotherapy notes

  • Progress Notes are tied to the Medical Record of a Client.
    If you are required to share client records with other professionals or insurance companies, the progress note for each appointment will be included when you print out the note.
  • Psychotherapy notes are not tied to the Medical Record of the Client and do not need to be shared with others except if your records are subpoenaed. 

    To lock and sign a progress note, click Lock this note. If you are pre-licensed under supervision, you have the option to Sign & Share with your Supervisor. You will know the note is locked because you will see a message like this one:


Adding a note

Notes are added on the Session Details page. You can access this page from the calendar or from the client's chart.

Option 1.

  1. Select the appointment from the Calendar page.
  2. A link to Add Note will indicate that a note has not yet been written.
  3. Click the link to access the Session Details page.


Option 2.

  1. Go to Clients > Client Name.
  2. Click Add Progress Note button.


How to write your progress and psychotherapy notes

Once you are on the Progress Note page, simply start typing into the blank box provided.  

  1. Click Load Previous Note to load (and edit) the previous Progress note. This will pull forward your previous appointment's Progress note for this client, as shown below.
  2. Once on the Session Details page, type your Progress and/or Psychotherapy notes in the appropriate fields.
  3. Click Save.

Note: 
1. When a clinician's specialty is set to anything other than Behavioral Health Therapist or Substance Abuse Counselor all reference to Psychotherapy Notes on sessions she or he is assigned to will not be available as this is not typically a field that they would need.
2. If a clinician with a specialty other than Behavioral Health Therapist or Substance Abuse Counselor has previously saved a Psychotherapy note for a client, she or he will still have access to this field.
3. If a clinician's specialty is changed to Behavioral Health Therapist or Substance Abuse Counselor, the Psychotherapy note field and "add psychotherapy note" link will start displaying for all of this clinician's client sessions (both past and future).


How to edit or delete an existing note

Editing a Note

Here's how to edit an existing note:

  1. Hover your cursor over a note to display Edit, as shown below.
  2. Click Edit.
  3. Make any changes you like, then click Save.

Deleting a Note

Here's how to delete an existing note:

  1. Hover your cursor over a note to display Delete.
  2. Click Delete to permanently delete the note.

Note: Be careful, there is no way to recover a deleted note. We cannot recover a note you have deleted.   


Printing a note

Here's how to print a note:

  1. Once you've saved a Progress Note or a Psychotherapy Note for a client, you will see that you now have the option to print.
  2. Click Print, choose which document(s) you would like to print, and then press the Print button once more to be taken to the options for printing.

 

 

 

 

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