Skip to main content

Customize Progress Notes

TherapyNotes now gives you the flexibility to create Progress Notes Templates that fit your workflow. Start with one of our pre-built note templates by previewing it in your Library, copying it into the Note Template builder, and customizing it to your needs. From the Builder, you can easily add or remove components, giving you complete control over the structure of your notes.

Starting from a SOAP, DAP, BIRP, or the TherapyNotes Standard template, we now make it easier to tailor notes to your practice’s needs. 

Role Required: Practice Administrator or Clinical Administrator

 

Note Templates Library

Click Library > Note Templates tab

The Note Templates Library offers four pre-built note templates to use as-is or customize:

  • BIRP Progress Note
  • DAP Progress Note
  • SOAP Progress Note
  • TherapyNotes Progress Note (default)

You can Preview, Edit, or Copy and Customize any template. 

669ee32d-12a5-47df-873b-1cf9b015cb9c.png

(A) Status Filter: The template status can be filtered by Show All, Active, Inactive, and Draft to find the most relevant option.

(B) + Create Template: This allows you to start a new template from scratch or from an existing one.

(C) Edit or Copy: Click the Edit icon to change the Note Display Title, Description, or Status (Active/Inactive).

  • Active templates appear in the Template Selector when creating a note.
  • Inactive templates are hidden from clinicians. 

Click the Copy icon to duplicate a template. The copied template opens in the Template Builder, where you can edit and customize it. 

0f8217be-dae7-49c4-a9c1-40a9b5f252b8.png

For more information on our pre-built templates and their use, read Pre-Built Progress Note Templates.

 

Creating a Note Template

Setting Up Your Custom Template

Click Library > Note Templates tab > + Create Template button

The Note Template Builder allows you to customize Progress Note templates to meet your clinical needs. 

  • In the Create Template page, select Progress Note as the Note Type.
  • In the Start With dropdown, select a Standard or Custom Template to work from.
925c2e69-bbb2-46db-b14e-0e6afafc03ef.png
  • Enter the following:
    • Template Name: How the name will display in the Library and in the Template Selector dropdown when a note is being created.
    • Note Display Title: The default title of the note clinicians see when creating the note.
    • Description (optional).
b122fda4-b9f7-4ccc-bb5b-d439318dfb89.png

Build & Organize Your Template

The Template Builder offers full control over the layout and content of your note. Simply hover over any of the existing elements to open the Add Element menu by clicking the + icon.

  • Reorder elements by using the up/down arrows or by dragging them.
9c3275fa-b050-4dff-aeb2-15315f78f6e2.png
  • The Add Element menu offers several elements from our existing Progress Note template as well as generic elements to tailor your note template. Existing Progress Note elements include:
    • Risk Assessment
    • Outcome Measures
    • Current Mental Status
    • Medications
    • Interventions Used 
add-element-prog.png
Note: Greyed out elements indicate that they are already in the template and cannot be duplicated.
  • Progress Note templates require the following elements at minimum:
    • Diagnosis
    • Treatment Plan Progress
    • Recommendation
    • Signature

The following Note Template elements can be added to your template to meet your clinical needs:

  • Read-only Text: Use the built-in rich text editor to add headings, paragraphs, quotes, and formatted text (bold, italic, underline, lists, and indents).
readonlytext-component.png
  • Long/Short Response: Collect short (max 500 characters) or long (max 6000 characters) written responses. These responses can be marked as required or optional. 
longresponse-element.png
Note: Long Response fields have associated Smart IDs where you can select a field from the dropdown that is associated with built-in History or TherapyFuel Outputs. 
  • Choice (single-select, checkboxes, dropdown): Present multiple choices where only one option can be selected. These responses can be marked as required or optional. All options, whether selected or not, will be shown on the completed template.

choice-element.png

  • Note elements can be removed by clicking the element and selecting the X icon.
remove-element.png
  • If your practice uses TherapyFuel, a toggle for Use TherapyFuel will appear for supported fields to enable it when completing the note.
3e917819-4ad1-4835-9153-df639fabe448.png
  • When you’ve finished building your template, click Save and Set Active. It’s now ready to be used by clinicians.  

To learn more about using the pre-built and custom templates, read Writing Notes with Progress Note Templates.

 

Editing Your Custom Template

To update a custom template from your Note Templates library:

  • Go to Library > Note Templates > Select the Edit icon for the corresponding template.
  • Use the Template Builder tools to make your changes.
  • To delete the template, click the Delete Template link at the bottom right corner.
    • A warning will appear to confirm that you want to permanently delete this template. Click the Delete Template button.
  • Once you’re finished, click Save Changes to apply your updates. 
Powered by Zendesk