For every client appointment, you can add a progress note and a psychotherapy note from the Session Details page.
Below, you can learn more about...
- Progress & psychotherapy notes
- Adding a note
- How to write your progress and psychotherapy notes
- How to edit or delete an existing note
- Printing a note
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, appointment flyout window, or from the client's chart.
- Click the note icon on the appointment while on the Week view of the calendar.
- Click the appointment from the Calendar page.
- Click the Add Note link.
- Navigate to the client's Overview page.
- Click Add Progress Note.
How to write your progress and psychotherapy notes
Once you are on the Progress Note page, simply start typing into the blank box provided.
- If you are on the Essential Plan, you will be able to select a Simple Progress note (blank) or populate the note field with a SOAP or DAP note.
- On the Professional Plan, you can select from your list of customized notes templates. We have provided a note template as an example.
- 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.
- Once on the Session Details page, type your Progress and/or Psychotherapy notes in the appropriate fields.
- Click Save.
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:
- Hover your cursor over a note to display Edit, as shown below.
- Click Edit.
- Make any changes you like, then click Save.
Deleting a Note
Here's how to delete an existing note:
- Hover your cursor over a note to display Delete.
- 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:
- 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.
- 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.