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.

Role Required: Clinician, Intern, Supervisor, or Clinical Administrator

Before creating a Consultation Note:

Ensure that you have service codes entered under the Consultation service type. For more information, read Add, Edit, and Delete Service Codes.
Schedule an appointment and select Consultation from the Type dropdown.

Tip: Consultation Notes are billable, but you may occasionally decide to offer free consultations to clients. To create a Consultation Note for a free session, create a service code using the Consultation service type and enter 0 for the Standard Rate.

To create a Consultation Note:

Click To-Do
Click the Create a Consultation Note link for the appointment you want to create a note for

To learn more about creating notes and note writing tools in TherapyNotes, read Create a Note.

Note Header

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.

Diagnosis

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

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.

Tip: To create a basic custom template that you can use for future Consultation Notes, use the Note Content field to create your own headers and organization. For future Consultation Notes, click the History button > Use to pull the text forward and keep your template consistent.

Sign and Save

Once you have completed your Consultation Note, select the Sign this Form checkbox to electronically sign the note and click the Create Note button.

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.

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.