Creating a progress note

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The difference between a progress note and psychotherapy note

For every appointment, you can add a progress note and a psychotherapy note

  • 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 session will be included when you print out the note. You can edit the progress note as much as you want until you lock and sign it.
  • Psychotherapy Notes are not tied to the medical record of the client and do not need to to be shared with others except if your records are subpoenaed. 

To lock and sign a progress note, click Lock this note.

Note: Once locked and signed, you cannot edit this note and it goes on the client's permanent record.

How to add progress and psychotherapy notes

Notes are added on the session details page. You can access this page from two locations.

From the homepage:

  1. Select the appointment from the calendar page. A note icon will indicate that a note has not yet been written.   SP-HelpCenter-Screenshots-55.png
  2. Click the note icon to open the progress note page. 

From the list of appointments displayed on the client overview page:

  1. Go to Clients > Select your Client.  
  2. Select Add Progress Note to open the Session Details page where you can add the progress and/or psychotherapy Note.
  3. Once a progress or psychotherapy note has been created for a session, you can access the note(s) on the Session Details page by selecting View Note.
  4. To access the Session Details page from the Client Details page, you can select either the Session Date or, if there is no note yet created, the Add Note button.

How to edit or delete an existing note

Editing a Note

Here's how to edit an existing note:

  1. Hover your cursor over a note to display Edit, as shown below.SP-HelpCenter-Screenshots-57.png
  2. Click Edit.
  3. Make any changes you like, then click Save.

Deleting a Note

Here's how to delete an existing note:

  1. Hover your cursor over a note to display Delete (unless the note is locked).
  2. Click Delete to permanently delete the note.

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

How to write a progress note

  1. Once you are on the progress note page, simply start typing into the blank box provided. 
  2. If you are on the Essential Plan, you will be able to select a Simple Progress note (blank). On the Professional Plan, you can select from your list of customized notes templates.  We have provided a note template as an example.

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You can load (and edit) the previous note by selecting the icon in the upper right corner. 

SP-HelpCenter-Screenshots-61.pngOnce on the Session Details page, type your Progress and/or Psychotherapy notes in the appropriate fields. 

When you have completed your notes, be sure to click Save.

Note: To learn more about using Notes Templates (Professional Plan), click here.

Attaching a file to a progress note

If you have documents or files you'd like to associate with a session, you can attach them to the progress note.

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Click the "Store New Document" button on the session detail page. Then select the file you'd like to upload from your computer. You can upload any file type as long as it doesn't exceed 10 MB. Once the file is uploaded, you can edit the file name or delete the file by clicking the icons next to the file name.

Files uploaded to a session will also appear in the Stored Documents section of the Client's Overview page.

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Locking and signing the progress note

At any time you can lock and sign the Progress Note by hovering your cursor over the notes so the Lock button appears.

Note: Once the lock button is clicked, you cannot edit this note.

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