For every client appointment, you can add a progress note and a psychotherapy note from the Session page.
- Progress and psychotherapy notes
- Adding a note
- How to write your progress and psychotherapy notes
- How to edit or delete an existing unlocked note
- How to lock and share notes
- How to amend, correct, or clarify a locked note
- How to grant or revoke clinician access to unlock locked progress notes (group practices only)
- Printing a note
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.
Adding a note
Notes are added on the Session page. You can access this page from the Calendar, appointment flyout window, 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
- From the appointment flyout
- Click the appointment from the Calendar page
- Click the Add Note link
- From the client's Overview page
- Navigate to the client's Overview page
- Find the correct appointment and click Add Progress Note or Add Psychotherapy Note to go to the Session page
How to write your progress and psychotherapy notes
Once you are on the Session page, simply start typing into the blank box provided.
- If you are on the Essential Plan, you'll 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.
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.
- 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:
- Next to the progress note, click Edit
- Make any changes you need, then click Save
To delete an existing unlocked note:
- Next to the Created message for the progress note, click Delete
- Click Delete to permanently delete the note
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 share notes
To lock and sign a progress note, click Lock.
You will then see the Lock & Sign Progress Note prompt. Click Lock Now to proceed.
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.
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 next to the Locked and Signed message for the progress note
- 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.
- Once you click Accept & Unlock, you'll see the Unlocked message beneath the progress note.
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.
- Click Update Team Member.
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'll 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.