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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 or a psychotherapy note from the Appointment page.

In this guide, we'll cover:


Progress and psychotherapy notes

Progress Notes are tied to the medical record of a client.

  • If you’re required to share client records with other professionals or insurance companies, the progress note for each appointment will be included if you print it out.

Psychotherapy notes aren’t tied to the medical record of the client, and don’t 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. 

Tip: You can use the Appointment Status report to find any appointments that are missing progress notes. See Appointment Status Report: Checking the billing and documentation status for appointments for additional details.


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 appointment  flyout, or from the client's Overview page.

Note: Only one progress note can be saved per date of service. If you’d like to add additional progress notes, you can create the note as an Assessment and add it to the client’s file. See Adding an assessment to a client's chart for more information. 

From the Calendar

Click the note icon on the appointment while on the Week view of the calendar

addnote.simplepractice.calendar.png

From the appointment flyout

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

addnote.simplepractice.calendarflyout.png

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

%2Bprogreenote.simplepractice.overview.png


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: 

appointmentdetails.simplepractice.clientdetails.png

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:

gotobilling.simplepractice.appointmentdetails.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 Manage treatment plans in the upper right corner of the Appointment page to open the client’s Diagnosis & Treatment Plan(s) in a side flyout alongside your Progress Notes, without interrupting the note you’re currently writing:

editdiagnosisandtreatmentplan.simplepractice.appointmentdetailspage.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 and 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:

editdateandtime.simplepractice.progreenote.png

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

upcoming_previousappointment.simplepractice.progreenote.png

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 Sign.

Important: While our system will autosave a draft of your note in some instances, it's important to make sure that you Save your note anytime you leave your browser page to ensure you don't lose your work. If you try to leave your browser without saving your note, you'll see a pop-up modal letting you know any changes you made may not be saved.


Writing your progress and psychotherapy notes

On the Appointment page, you can select which progress note template you’d like to use from the drop-down menu.

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After selecting a template, you can begin writing your note by typing in the blank box provided.

simpleprogressnote.simplepractice.appointmentpage.png

You can also 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:

attachment.simplepractice.progressnote.png

Please note: 

  • When a clinician's specialty is set to anything other than Behavioral health therapy, Substance use counseling, Marriage and family therapy, Psychology, Social work, or Counseling, 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 therapy, Substance use counseling, Marriage and family therapy, Psychology, Social work, or Counseling 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 therapy, Substance use counseling, Marriage and family therapy, Psychology, Social work, or Counseling, the Psychotherapy note field and Add Psychotherapy Note link will start displaying for all of this clinician's appointments, both past and future.

Editing and deleting 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

editprogreenote.simplepractice.progreenote.png

To delete an existing unlocked note

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

deleteprogreenote.simplepractice.appointmentdetails.png

Note: Be careful, as there is no way to recover a deleted note, and we can't recover a note you have deleted.  


Locking and signing notes

To sign a progress note, click Sign.

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On the Sign and Lock Progress Note flyout, review the signature preview. You can edit the Provider Name and Credentials as needed. Click Sign & Lock when ready.

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Note: For your first signature, the Provider Name and Credentials will automatically populate from Settings > My Profile > Clinical. Once you edit the Provider Name and Credentials on the Sign and lock Progress Note flyout, it’ll save your edits going forward for future progress notes.

Once the note is locked, you'll see the Provider Signature that includes the clinician's name, signature, license type, and the date and time at which the note was locked.

signedbyclinician.simplepractice.progreenote.png

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

Note: There isn't a way to customize this signature.


Sharing a progress note with a client for e-signature

After signing and locking a progress note, you can share it via the Client Portal to be signed electronically by a client or contact. To do this: 

  • Navigate to the client's Overview page and click the appointment associated with the progress note
  • Select Share

shareprogressnote.simplepractice.progressnote.png

  • Review the attached document and click Continue to Email

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Once the client or contact signs the document, you'll see the Provider and Client/Contact signatures in the appointment's details. 

lockedprogreenote.simplepractice.progreenote.png

 


Amending, correcting, or clarifying 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 not

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  • 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.

acceptandunlock.simplepractice.progreenote.png

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

unlockedprogressnote.simplepractice.progressnotes.png

Important: A progress note that's been signed by a client or contact can't be unlocked or edited. 


Granting or revoking clinician access to unlock locked progress notes (group practices only)

As an Account Owner, you can grant or revoke other clinicians' ability to unlock their own notes in your practice: 

  • Go to Settings > Team Members and click the name of the clinician you want to edit permissions 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.

unlockprogressnotes.simplepractice.permissions.png

  • Click Update Team Member.

Tip: Practice Managers can also adjust clinician permissions. 


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.

printprogreenote.simplepractice.progreenote.png

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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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.

downloadednote.simplepractice.progressnote.png

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