Contact Notes are used to record conversations/ interactions between a staff member and a client or a client’s contact. Contact Notes are administrative and help keep track of communication. If you plan to charge for the interaction documented in the Note, a Contact Note will also create a billing entry.
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 Create a Note.
The note header includes key information such as the client’s name, insurance details, the note’s date and time, and the authoring staff member. To make changes, click anywhere in the note header or select Edit in the upper-right corner.
Contacted Party
Select the individual with whom communication occurred:
- Click the Name field to choose the client’s existing contacts. This auto-fills the Name and Relationship to Patient fields.
- If the contact is not listed, manually enter the information and select a relationship type from the dropdown.
Method of Communication
Choose how the communication occurred. Multiple options can be selected if more than one method was used.
Reason for Communication
Click in the Reason for Communication field to select from a list of common responses or enter a custom reason. Some common reasons include billing, changes in medication, check-ins, and crisis interventions.
Billing Information
Enter the total minutes spent on communication across all selected methods.
If you plan to bill for the communication:
- Check The patient will be billed for this communication.
- This generates a billing line item with Contact as the service type.
Communication Details
Use this section to document the content of the exchange, including who initiated the contact and what was discussed or resolved.
Sign and Save
Once you have completed your Contact Note, select the Sign this Form checkbox to sign the note electronically. Select whether the note should be visible only to clinicians assigned to the client or all users from the Note is Visible dropdown. Click the Create Note button.
To save your work without signing, leave Sign this Form unchecked. Click Save Draft. Access drafts later from your To-Do list or through Patients > Patient Name > Documents.