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Using progress and psychotherapy notes

Using progress and psychotherapy notes

You can add a progress note or a psychotherapy note for every client appointment 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 in the records and data exports.

Note: There isn’t a way to require adding a progress note to appointments before billing them.

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.

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 to learn more.


Adding a note from the Appointment page

Progress notes and psychotherapy notes are managed on the Appointment page for a date of service. You can access this page from the calendar, an appointment flyout, or 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 add the note to the client’s file as an other document. For more information, see Adding an other document to a client's file.

From the calendar

To add a note from the calendar, click the note icon on the appointment while in Week view:

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Note: To learn more, see Understanding the progress note indicator.

From the appointment flyout

To add a note from the appointment flyout:

  • Navigate to the Calendar 
  • Select the appointment
  • Click Add Note

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From the client's Overview page

To add a note from the client’s Overview page:

  • Navigate to the client's Overview page
  • Find the appointment in question
  • Click + Progress Note or + Psychotherapy Note

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  • If your client’s Overview page is set to List View, hover your cursor over the appointment and click Edit

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Note: To learn more about your view options on the client Overview page, see Changing your view.


The Appointment page provides relevant information you need when writing notes for clients.

Your clients’ contact information and date of birth are located at the top of the page for you to reference while writing a note.

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Under the Appointment Info tab, you can view the appointment’s date, time, status, duration, and location. If you need to correct the date, start time, or duration for a date of service, click Edit.

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You can also click Open in Calendar to jump to the calendar in another tab, where you can update other details, such as the clinician or location assigned to the appointment.

Under Services, you can view the appointment’s billing code(s) and their respective fees. In the Billing section, you’ll find the billing type, appointment total, and payment status. Selecting Open billing will take you to your client’s Billing tab, where you can view or edit the appointment’s billing details.

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You’ll also see the client’s previous and next appointments, if applicable. If needed, you can select either appointment to view its respective Appointment page.

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Note: The billing details for an appointment will only appear if they have the appropriate access level. To learn more, see Team member roles and access levels.

At any point while writing a note, you can click Save to keep your progress.

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You can then Edit, Delete, or Sign the saved note.

Important: While SimplePractice will autosave a draft of your note in some instances, it's important that you click Save on the note anytime you leave your browser page so that you don't lose your work. Our autosave functionality saves your progress via your browser's cookies, so clearing your cookies or opening the note on a different device or computer won’t display your autosaved note. If you try to leave your browser without manually 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 dropdown menu.

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After selecting a template, you can begin typing in the blank text box(es).

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Tip: When writing your notes, you can save time with snippets and macros. To learn more, see Using snippets.

You can also click Load last note to populate and edit the content of the client’s last progress note.

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Note: Load last note is only available on the Essential and Plus plans.

Selecting the arrow next to Load last note will open a dropdown menu where you can choose which of the client’s previous notes to load.

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The dropdown menu will display the client’s last 25 notes from newest to oldest.

To add an attachment to a progress note, click the paper clip icon.

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After clicking this icon, select the file you'd like to attach, and click Upload. Click Save after any changes are made. 

You can also add Psychotherapy Notes from the Appointments page. To do so:

  • Navigate to the Appointment page
  • Click Add note

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  • In the text box, enter the note details
  • When finished, click Save

Some important details to keep in mind about Psychotherapy Notes include:

  • The Psychotherapy Note field will only appear if the appointment is assigned to a clinician with one of the following specialties:
    • Behavioral health therapy
    • Substance use counseling
    • Marriage and family therapy
    • Psychology
    • Social work
    • Counseling
  • If a clinician with a differing specialty has previously saved a Psychotherapy Note for a client, they’ll still have access to this field
  • If a clinician's specialty is changed to one listed above, the Psychotherapy Note field will be displayed for all of the clinician's past and future appointments

Viewing documentation history

When writing a progress or psychotherapy note, click Documentation to conveniently view past:

  • Chart notes
  • Diagnosis and treatment plans
  • Mental status exams
  • Other documents
  • Progress notes
  • Psychotherapy notes
  • Questionnaires

documentation.simplepractice.progressnote.png

Clicking Documentation will open a right side panel where you can use the dropdown menus to view specific documentation for the client.

  • To adjust the date range, click All Time
  • To sort by document type, click All Items
  • To exit the Documentation history panel, click X

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Tracking treatment progress

While writing a progress note for a client, you can also track treatment progress directly from the Appointment page. To do this:

  • Navigate to the client’s Appointment page
  • Select the Treatment progress tab
  • Click + Start tracking progress

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Note: Tracking treatment progress is only available for clients using Wiley Treatment Plans.

  • Select the box for each goal or objective to update its status
  • Add a description as needed
  • If you’d like to include this information with the appointment’s progress note, keep the box checked for Include in this appointment's progress note

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    • If this box is grayed out, you first need to save the progress note

Note: Checking this box will include treatment progress in the progress note and on downloaded progress note PDFs and data exports. Unchecking this box will still save the treatment progress, but it won’t appear within the appointment’s progress note.

  • Click Save

Your updates will be saved on the Appointment page under Treatment progress going forward.

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Editing and deleting an existing unlocked note

To edit an unlocked note:

  • At the top of the Progress Note, click Edit

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  • Make any changes you need, then click Save

To delete an unlocked note:

  • Click More
  • Select Delete

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  • Click Delete now to permanently delete the note

Important: There’s no way to recover a deleted note.


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 and lock

Note: For your first signature, Your Name will automatically populate from Settings > Profile > Profile and security. Additionally, your Credentials will populate from Settings > Profile > Clinical info. After you edit Your Name and Credentials on the Sign and lock progress note flyout, it’ll apply your edits for future progress notes.

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

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If you’re pre-licensed under supervision, you have the option to Sign and share with your supervisor.

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


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 for electronic signature from a client or contact. To do this:

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

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  • Click Continue to Email
  • Review the email copy and select Continue to Review
  • Click Share & Send Now

Once the client or contact signs the document, you'll see the Provider and Client/Contact signatures on the Appointment page.

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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. Account Owners and clinicians who have been granted this permission can unlock progress notes to make amendments, corrections, or clarifications.

This feature should be used with care and in a manner that's consistent with HIPAA requirements and professional ethics, which include:

  • Being vigilant about maintaining the security and privacy of your SimplePractice account, such as using antivirus software, strong passwords for your accounts and your devices, maintaining a safe environment for storing your records, and taking other necessary precautions
    • Find more information on recommended practices on our Security page
  • Making sure you’re always logged in to your own account and never sharing accounts with others, including team members
  • Monitoring and auditing your Account Activity on a regular schedule to identify any unusual behavior immediately
  • Training 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 team members are ultimately responsible for safeguarding the information in your SimplePractice account.

For more information, see:

To unlock a locked progress note:

  • Navigate to the client's Appointment page
  • Click Unlock at the top of the note

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  • Under the Notice of Data Integrity, type the Reason for unlocking in the text field
  • Click Accept & Unlock

You'll see the Unlocked message beneath the progress note.

 

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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

As an Account Owner or practice manager, you can grant or revoke a clinician’s ability to unlock their own notes in your practice. To do this:

  • Navigate to Settings > Team > Team members
  • Click the name of the clinician you want to edit permissions for
  • Scroll to the Role info section, and click Edit
  • Update the Clinical roles and any applicable Administrative roles for the clinician, if necessary
  • Click Continue 
  • Toggle on the option to Unlock progress notes to grant the clinician access, or toggle it off to revoke their access

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Note: Account Owners and practice managers can also update a clinician’s access to unlock other documents and/or diagnosis and treatment plans.

  • Click Continue
  • Select Save changes

Printing and downloading a note

When reviewing a progress note or psychotherapy note, you’ll see the option to print that note. To do this:

  • Click More
  • Select Print, and a new tab will open to print your note

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To download a PDF version of a note:

  • Click More
  • Select Download

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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 practice logo, if you've added one to your settings. Additionally,  your client’s name and DOB will appear on every page. Your license number(s) and license type(s) are included in the Provider License section on Page 1.

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