How To: Complete a Consultation Note

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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: 

Quick Tip: Quick 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 the Consultation Note as you normally would. After the session, click Patients > Patient Name > Patient Billing tab and click on the date of service for the session. Select Direct from the Method dropdown, select the Write Off Patient Balance checkbox, and click Save Changes.

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.

Note Header

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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

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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

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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.

Quick 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

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.

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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.

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Comments

  • Avatar
    Michelle Bancroft

    Is there a way for the default for to-do to be "consultation note" instead of progress note?

  • Avatar
    Rachael

    Michelle,

    To make the Consultation note template the default, you will need to set the 'Service Type' to 'Consultation' when scheduling appointments. This way, you will be prompted to complete the Consultation note template in your to do, rather than the progress note. Please let us know if you have any questions. Thank you!