Contact Notes are non-clinical notes used to document communication between a staff member and a client or a client's contact. If you intend to charge for the communication, a Contact also creates a billing line item.
To create a Contact Note:
- Click Patients > Patient Name > Documents tab
- Click the Create Note button
- From the list that appears, select Contact Note
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 client, the client's insurance, the date and time the note was written, and which staff member created the note. To edit information in the note header such as the Note Title or Date & Time, click anywhere on the note header or click Edit in the upper right corner.
Click in the Name field to select from a list of the client's contacts. Your selection will autofill both the Name and Relationship to Patient fields.
Alternatively, enter a Name for a contact that is not included in the client's contacts. Click in the Relationship to Patient field to select from a list of common types of contacts.
Method of Communication
Select how you communicated with the contact. Multiple options may be selected to account for the full exchange with the contact.
Reason for Communication
Click in the Reason for Communication field to select from a list of common responses, or enter a custom reason.
Enter the total number of minutes you spent communicating with the contact across all of the communication methods indicated in the Method of Communication section. If you intend to bill for your communication with the client, select The patient will be billed for this communication. A billing line item will be generated for the communication with Contact entered for Type and Diagnosis and Direct entered for Payer.
Enter any details related to the communication, including who contacted whom and what was accomplished through the communication.
Sign and Save
Note: In order to save a Contact Note, you must enter the Name and Relationship to Patient for the Contacted Party, Method of Communication, and Reason for Communication. All other fields are optional.
Once you have completed your Contact Note, select the Sign this Form checkbox to electronically sign the note. Select whether the note should be visible only to clinicians assigned to the client or to all users from the Note is visible to dropdown. Click the Create Note button.
To save an unfinished Contact Note, leave Sign this Form unchecked and click the Save Draft button. You may access your draft later from your To-Do list or click Patients > Patient Name > Documents tab.