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How to use progress and psychotherapy notes

How to use progress and psychotherapy notes

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


Progress and 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. 

Note: SimplePractice is flexible in allowing clinicians to have their own preferred workflows, so there isn't a way to require adding a note to appointments before billing them. 


Adding a note from the Appointment page

Progress notes and psychotherapy notes are managed on the Appointment page associated with a date of service. You can access this page from the Calendar homepage, the Calendar flyout, or from the client's Overview page.

  • From the Calendar
    • Click the note icon on the appointment while on the Week view of the calendar 

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  • From the appointment flyout
    • Click the appointment from the Calendar page
    • Click Add Note

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  • From the client's Overview page
    • Navigate to the client's Overview page
    • Find the correct appointment and click + Progress Note or + Psychotherapy Note to go to the Appointment page

progressnote.simplepractice.overview.jpg


We’ve carefully redesigned the Appointment page to simplify your workflow and provide the relevant information you may need to reference or update when writing client notes. 

With this enhancement, your clients’ contact information, date of birth, and appointment information are now all located at the top of the page for you to reference while writing a note: 

appointmentpage.simplepractice.appointmentinfo.jpg

Select the Services tab to view the Billing Type, Total Fees, and CPT code for the appointment, and click Go to Billing if you need to make any adjustments:

Services.SimplePractice.AppointmentPage.png

Note: The billing details for an appointment will only be available if the team member has the appropriate access level.

You can also click Diagnosis & Treatment Plan in the upper right corner of the Appointment page to open the client’s Diagnosis & Treatment Plans in a side flyout alongside your Progress Notes, without interrupting the note you’re currently writing:

Progressnote.SimplePractice.Diagnosis.png

This is especially useful if you need to quickly copy and paste any relevant information from the Diagnosis or Treatment Plan to include in your notes.

If you need to correct the date, start time, or duration for a date of service, click Edit Date & Time to make adjustments directly from the Appointment page. Or, click Open in Calendar to jump to the Calendar homepage in another tab where you can update other details such as the clinician or location assigned to the appointment:

EditDate.SimplePractice.AppointmentPage.png

If needed, jump ahead to the Appointment page for the client’s upcoming appointment, or back to a past appointment:

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At any point while writing a note, you can click Save to keep your progress and leave the screen. Then, return another time to finalize the saved note before clicking Lock & Sign.

Important: The system will autosave your work as you write Progress and Psychotherapy notes so you won't lose progress if you exit the page, but keep in mind that this is not a true save and the data will only be stored locally to your browser. This means that the content of an unsaved note will not carry over to another device or browser, and the content will be lost if you clear your cache. To keep a complete note records for your clients, it's important that you always click Save to keep your progress and that you Lock & Sign your notes once they're finalized.


How to write your progress and psychotherapy notes

Once you're on the Appointment page, simply start typing into the blank box provided.  

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You can click Load Previous Note to load and then edit the content of the progress note from the client's last appointment for the current appointment. 

loadpreviousnote.simplepractice.progressnote.png

To add an attachment to a progress note, click the paper clip icon, select the file you'd like to attach, and click Upload:

addattachment.simplepractice.progressnote.png

Please note: 

  • When a clinician's specialty is set to anything other than Behavioral Health Therapist or Substance Abuse Counselor, all references 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.
  • 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.
  • 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 appointments, both past and future.

How to edit or delete an existing unlocked note

To edit an existing unlocked note:

  • At the top of the Progress Note, click Edit
  • Make any changes you need, then click Save

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To delete an existing unlocked note:

  • Next to the Edit button, click Delete
  • Click Delete now to permanently delete the note

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


How to lock and sign notes

To lock and sign a progress note, click Lock & Sign.

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You will then see the Lock & Sign Progress note prompt. Click Lock Now to proceed.

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Once the note is locked, you'll see the Locked and Signed message that includes the clinician's name and the date and time at which the note was locked.

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If you are pre-licensed under supervision, you have the option to Sign & Share with your Supervisor.


How to amend, correct, or clarify a locked note

Progress notes are important for creating a legal health record of your client encounters, client billing, and measuring client progress. The Unlock Progress Notes feature allows you - the account owner - to unlock your or a colleague’s progress notes to make amendments, corrections, or clarifications. 

This feature should be used with care. You’ll need to implement some best practices to use it in a way that is consistent with HIPAA requirements and professional ethics:

  • Be vigilant about maintaining the security and privacy of your SimplePractice account. This means using antivirus software, using strong passwords for your accounts and your devices, maintaining a safe environment for storing your records, and taking other precautions you deem necessary. Find more information on recommended practices by reviewing our Security page. 
  • Make sure you’re always logged in to your own account and never share accounts with others, even other users in your own SimplePractice account. 
  • Any time the Unlock feature is used, a new entry will be logged in your Account Activity. You can learn more here: Account Activity: Tracking changes and information access in your account.
  • Monitor and audit your Account Activity on a regular schedule to identify any unusual behavior right away.
  • Train your HIPAA Workforce, including clinical and administrative staff, in accordance with the Privacy and Security Rules.

While this feature is built in a HIPAA-compliant way, you and your fellow clinicians are ultimately responsible for safeguarding the information in your SimplePractice account.

For more information, please review these helpful resources:

To unlock a locked progress note:

  • Click Unlock at the top of the noteunlocknote.simplepractice.progressnote.jpg
  • You'll then see the Notice of Data Integrity. You'll need to type the Reason for unlocking in the text field and click Accept & Unlock to unlocked the locked progress note.

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  • Once you click Accept & Unlock, you'll see the Unlocked message beneath the progress note.

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How to grant or revoke clinician access to unlock locked progress notes (group practices only)

As the SimplePractice account owner, you can grant or revoke other clinicians' ability to unlock their own notes in your practice. 

  • Go to My Account > Settings > Team Members and click the name of the clinician you want to grant access for.
  • Scroll to the Permissions section, and check the Allow clinician to unlock Progress Notes checkbox to grant the clinician this access, or uncheck the checkbox to revoke this clinician's access.

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  • Click Update Team Member.

Printing and downloading a note

Here's how to print a note:

  • Once you've saved a progress note or a psychotherapy note for a client, you'll see the option to print.
  • Click the printer icon, and a new tab will open to print your note.

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To download a note:

  • Select the download icon, located next to the printer icon.
  • A PDF version of your note will be downloaded.

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Tip: If you need to share a note, you can download and save it, then reupload it to the client's profile and share it. For more information on sharing documents with clients, check out this guide: Sending intake forms and documents to clients.

Your printed notes and documents will contain all the information auditors, insurance companies, and other third parties require in an easy-to-read format. All exported documents will include your logo if you've added one to your settings, your client’s name and DOB on every page, and your license number(s) and license type(s) in the Provider License section on Page 1.

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