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
- Adding a note from the Appointment page
- Navigating the Appointment page
- Writing your progress and psychotherapy notes
- Viewing documentation history
- Tracking treatment progress
- Editing or deleting an unlocked note
- Locking and signing notes
- Sharing a progress note with a client for e-signature
- Amending, correcting, or clarifying a locked note
- Granting or revoking clinician access to unlock locked progress notes (group practices only)
- Printing and downloading a note
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.
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: There isn’t a way to require adding a progress 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 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, the 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 create the note as an assessment and add it to the client’s file. For more information, see Adding an assessment to a client's chart.
From the Calendar homepage
To add a note from the calendar, click the note icon on the appointment while on the Week view:
Note: For additional details on the note icon on the Calendar homepage, see Understanding the progress note indicator.
From the appointment flyout
To add a note from the appointment flyout:
- Click the appointment from the calendar
- Click Add Note
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 to go to the Appointment page
- If your client’s Overview page is set to List View, hover your cursor over the appointment and click Edit to go to the Appointment page
Note: To learn more about your view options on the client Overview page, see Changing your view.
Navigating the Appointment page
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.
Under Appointment Info, you can view the appointment’s date, time, status, duration, and location. You’ll also see any previous or future appointments for the client. If needed, you can jump ahead to the Appointment page for the client’s upcoming appointment, or back to a past appointment.
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. You can also 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:
Select Services to view the Billing Type, Total Fees, Client Owes, and billing code for the appointment. Click Go to Billing if you need to make any adjustments:
Note: The billing details for an appointment will only appear if the team member has the appropriate access level. To learn more about team member access levels, see Team member roles and access levels.
Select Treatment progress to track your client’s progress toward their goals, and update their Wiley Treatment Plan without interrupting the note you’re currently writing.
You can click + Start tracking progress to begin.
Note: Treatment progress tracker is only available for clients using Wiley Treatment Plans. See Tracking treatment progress for more details.
You can also click Documentation history in the top right corner of the Appointment page to open the client’s past documentation and current treatment plan (if applicable) in a side flyout alongside your progress note:
Note: To learn more, see Viewing documentation history.
At any point while writing a note, you can click Save to keep your progress.
You can then Edit, Delete, or Sign the saved note.
Important: While our system will autosave a draft of your note in some instances, it's important to make sure that you click Save on the note anytime you leave your browser page to make sure 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. 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.
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.
- If you’re on the Starter plan, you'll be able to select a Simple Progress Note template or populate the note field with a SOAP or DAP template
- On the Essential and Plus plans, you can select from your list of customized notes templates
After selecting a template, you can begin typing in the blank text box.
You can also click Load last note to populate and edit the content of the client’s last progress note.
Note: Load last note is only available on the Essential and Plus plans.
Clicking the arrow next to Load last note will open a dropdown menu where you can choose to load and edit from the client’s previous notes. 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, select the file you'd like to attach, and click Upload:
Click Save after any changes are made.
Please note:
- The Psychotherapy Notes field will only appear if the appointment is assigned to a clinician with the Behavioral health therapy, Substance use counseling, Marriage and family therapy, Psychology, Social work, or Counseling specialty
- 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, they’ll 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 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 history to conveniently view past:
- Assessments
- Chart notes
- Diagnosis and treatment plans
- Mental status exams
- Progress notes
- Psychotherapy notes
- Questionnaires
Clicking Documentation history 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 remove the Documentation history panel, click X
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
- Click Treatment progress > + Start tracking progress
Note: Tracking treatment progress is only available for client’s 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
- 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 will appear with the appointment’s progress note
- Click Save
Your updates will be saved on the Appointment page under Treatment progress > History going forward.
Editing and deleting an existing unlocked note
To edit an unlocked note:
- At the top of the Progress Note, click Edit
- Make any changes you need, then click Save
To delete an unlocked note:
- Next to the Edit button, click Delete
- Click Delete now to permanently delete the note
Note: There’s no way to recover a deleted note.
Locking and signing notes
To sign a progress note:
- Click Sign
-
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
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 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.
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 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 to be signed electronically by a client or contact. To do this:
- Navigate to the client's Overview page
- Click the appointment associated with the progress note
- Select Share
- Click Continue to Email
Once the client or contact signs the document, you'll see the Provider and Client/Contact signatures in the appointment's details.
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:
-
Vigilance 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 precautions you deem necessary
- Find more information on recommended practices by reviewing our Security page
- Making sure you’re always logged in to your own account and never sharing accounts with others, including team members
-
Any time the Unlock feature is used, a new entry will be logged in your Account Activity
- For more information, see Account Activity: Tracking changes and information access in your account
- Keep in mind that any edits made to the progress note will overwrite the original note
- 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:
- Summary of the HIPAA Security Rule
- Security 101 for Covered Entities
- Electronic Health Records Provider fact sheet
To unlock a locked progress note:
- Click Unlock at the top of the note
- 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
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
- 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 access, or uncheck the checkbox to revoke their access
- Click Update Team Member
Tip: Practice Managers can also adjust clinician permissions.
Printing and downloading a note
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
To download a PDF version of a note:
- Select the download icon
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, as well as your client’s name and DOB on every page. Your license number(s) and license type(s) are included in the Provider License section on Page 1.
