Quick Start: Notes
TherapyNotes offers several robust note templates which are uniquely designed for behavioral health professionals. Each of our templates balance speed, ease-of-use, and clinically-rich, person-centered documentation using combinations of dropdown menus, checkboxes, and text fields to allow you to quickly, thoroughly, and accurately document the services you provide.
In order to create most notes, a corresponding appointment must be scheduled on the calendar. Since TherapyNotes links note templates to the service type you choose when scheduling an appointment, verify that the correct service is scheduled to access proper documentation. At the time of the appointment, a To-Do list item will be generated to remind you to complete the corresponding note. Once the note is completed and electronically signed, you can bill the service to insurance.
Understanding Your Clinical Documentation Workflow
In addition to pulling information forward from scheduled appointments, notes also pull information from previous notes to ensure consistency and efficient documentation. In a typical workflow, once a Therapy Intake or Psychiatry Intake is scheduled, TherapyNotes prompts you to complete an Intake Note followed by a Treatment Plan, which pulls information such as the diagnosis and presenting problem from the Intake Note. After subsequent sessions are held with the client, TherapyNotes prompts you to create Progress Notes for each session, and the Progress Note will pull information such as diagnoses and treatment objectives forward from the Treatment Plan.
Follow the steps below to learn more about our powerful notes system or click on any of the links below to jump to that section of the article.
Part 1: Set Up Default Note Settings
Customize your diagnosis codes
Note: Only Clinical Administrators can complete this step.
Click the User Icon > Settings > Diagnosis Codes (under Notes and Coding)
TherapyNotes includes DSM-5 diagnoses and ICD-10 diagnosis codes to identify a client's diagnosis on notes and for insurance billing.
To add a custom diagnosis code, click the + Add Custom Diagnosis Code button. To remove a diagnosis code that may not be relevant to your practice, click the Delete link next to the diagnosis code.
Customize your interventions list
Click the User Icon > Settings > Interventions (under Notes and Coding)
By default, TherapyNotes includes a list of commonly used interventions that are available as checkboxes on Progress Notes. Each Clinician, Intern, and Clinical Administrator can modify their interventions list to reflect the services they provide. The changes made by one user to their interventions list does not affect the interventions available for other users.
To add a custom intervention, type your intervention in the field at the bottom of the Customize Your Interventions dialog and click the Add Intervention button. To remove an intervention, click the X to the right of the intervention.
Choose what your printed notes contain
Note: Only Practice Administrators or Clinical Administrators can complete this step.
Click the User Icon > Settings > Note Settings
Configure what appears in the header of downloaded and printed notes by selecting or deselecting each item. When finished, click the Save Settings button.
Part 2: Creating Notes
Clinical notes require that the corresponding appointment has been scheduled and is in progress or has already occurred. Notes are not available for the appointment until 5 minutes before the appointment start time.
Most non-clinical notes do not require scheduled appointments to be created.
TherapyNotes offers several ways to create a note.
Create a note from your To-Do list
Your To-Do list in TherapyNotes is an automatically generated list of tasks that need to be completed, including documents to be collected, notes to be written, and billing items to be submitted and reviewed. When a note is ready to be written, an item for the note will be added to your To-Do list. Find the date of service to write a note for on your To-Do list and click the corresponding note link.
Your To-Do list is also available on several additional pages within TherapyNotes, including the Welcome page, the To-Do List tab of your staff profile, and the To-Do and Schedule tab of a specific client.
Create a note from the calendar
Click Scheduling > Click the appointment > Notes tab
Clicking on a past appointment brings up a dialog with access to appointment details, applicable notes, and billing items relevant to the session. In the Notes tab of this dialog, click on the link for the type of note you want to create.
Create a note without an appointment
Click Patients > Patient Name > Documents tab
Not all documentation in TherapyNotes is associated with an appointment. To view all of the note templates that you have access to in TherapyNotes, click the Create Note button. A list of available note templates will appear.
Different note types will be available depending on your role and clinician type (Psychotherapy or Medication Management). Only Clinical Administrators, Clinicians, and Interns assigned to the client plus Supervisors for the assigned clinicians have access to create and view clinical notes, including Intake Notes, Treatment Plans, Progress Notes, Consultation Notes, and session notes for unscheduled appointments. Contact Notes, Missed Appointment Notes, and Miscellaneous Notes may be created by any user.
For more information on note templates and features, read How To: Create a Note.
Part 3: Access Drafts and Completed Notes
If a note is saved without being electronically signed, TherapyNotes saves the note as a draft. An item will be automatically added to your To-Do list for any drafts that you should complete and sign.
To access all notes for a client, click Patients > Patient Name > Documents tab. This tab shows a chronological list of all notes and files for the client.
If a note is still in draft mode, the note will be highlighted in yellow. Access a note by clicking on the note type in the left column or using one of the action icons on the right. Click the pencil icon to edit the note or the cloud icon to download the note as a PDF. To download multiple notes at once in a single PDF, click the Download Multiple link below the list of notes and files and select the notes to download.
When viewing an existing note, a toolbar is available at the bottom of the page. This toolbar includes options to Edit, Download, or Print the note, as well as access to Revision History for the note. Revision History shows you what changes have been made to the note since it was first saved, which is useful for logging addendums to notes while maintaining the original date of documentation in the event of an audit. If you are a Clinical Administrator, you may delete the note from this toolbar.