Chart notes give you the flexibility to take note of anything relating to a particular client that’s not associated with a specific appointment. Chart notes appear in the client Overview page in chronological order, based on the date and time that’s set when adding the note.
In this guide, we'll cover:
Note: All clinicians and the Account Owner can view, edit, and add chart notes. Supervisors can do this for their supervisees’ clients. Practice managers, practice schedulers and practice billers can view, edit, and add chart notes with an optional permission. To learn more about optional team member permissions, see Team member roles and access levels.
Adding a chart note
Chart notes are tied to a client’s medical record. Some of the most common ways we see SimplePractice customers using this field is to record:
- Notes from a client phone call, email, Secure Messaging conversation, or document
- Comments about the client or appointment details
- Vitals (height, weight, BMI, blood work, etc.)
- Medication history
- Facesheet information
To create a chart note:
- Navigate to the client’s Overview page
- Type into the Chart Note field
- Set a specific date and time, if necessary
Tip: You can pin a chart note to the top of the client's record by setting the date to some time in the future. Since the client's record is organized chronologically, the chart note will stay at the top.
- Click + Add Note
Once added, you can view the client’s chart note on their Overview page.
Note: If you’re on the Essential or Plus plan, you can save time completing your chart notes with snippets and macros. To learn how these features work, see Using snippets.
You can view a client’s chart notes on their Overview page. To edit a chart note:
- Navigate to the client’s Overview page
- Hover your mouse over the Chart Note
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Click one of the following:
- Edit to update the chart note
- The print icon to print
- The trashcan icon to delete
- If you’re editing the chart note, click Save to keep your changes
- If you’re deleting the chart note, click Delete now
If you’re not able to view or choose one of the above options for an existing chart note, make sure that you’re viewing the client's Overview page in Excerpt View, not List View.
To change the view, click the Excerpt View icon below the Chart Note field. To learn more, see Changing your view.
Note: Chart notes can’t be signed and/or locked. Instead, you can add the note as an other document to e-sign it. To learn more about other documents, see Adding other documents, diagnoses, and treatment plans.