How To: Complete a Consultation Note
While most clinical notes in TherapyNotes feature robust templates to ensure that your notes are organized, clear, and complete, the Consultation Note offers more flexibility and consists of a note header, diagnosis fields, and a blank text field. Each Consultation Note corresponds to an appointment with a service code, allowing you to bill insurance for the session documented by the Consultation Note.
You are not required to complete a Treatment Plan before you create a Consultation Note, which is useful if you use multiple sessions to complete an Intake Assessment. Consultation Notes are also fantastic for documenting services not best served with a SOAP format, including a variety of specific interventions and billable case management activities.
Before creating a Consultation Note:
- Ensure that you have service codes nested under the Consultation service type. For more information, read How To: Add, Edit, and Delete Service Codes.
- Schedule an appointment and select Consultation from the Type dropdown
To create a Consultation Note:
- Click To-Do
- Click the Create a Consultation Note link for the date of service you want to create a note for
To learn more about creating notes and note writing tools in TherapyNotes, read How To: Create a Note.
The note header automatically fills in information for the clinician, client, and appointment, including relevant supervision information, client insurance, and service code. To edit information in the note header such as the Note Title or Service Code or to add information such as add-on codes, click anywhere on the note header or click Edit in the upper right corner.
The Diagnosis section will automatically populate a DSM-5 diagnosis code and description based on the information entered in the client's most recent note. These fields also feature searchable DSM-5 diagnoses, allowing you to easily edit existing or add additional diagnoses.
Note Content is blank text field with no limit to the number of characters you can enter. Use this field for any notes related to the session.
Sign and Save
Note: In order to save a Consultation Note, you must complete the Note Content field. If you intend to bill for the Consultation Note, you must also enter a diagnosis. All other fields are optional.
Once you have completed your Consultation Note, select the Sign this Form checkbox to electronically sign the note and click the Create Note button.
To save an unfinished Consultation Note, leave Sign this Form unchecked and click the Save Draft button. You may access your draft Consultation Note later from your To-Do list or click Patients > Patient Name > Documents tab.