Permissions: Therapist can create Notes for their assigned Cases, Administrators or higher can create Notes for all Cases.
There are several way to access and add a Progress Note for a Client. This is the My Clients Plus recommended workflow as it will link your Progress Note to a Client Appointment.
Jump to Section [Add Progress Note] [Complete Progress Note]
Add a Progress Note
- Be sure an Appointment has been created for this Client.
- On the Schedule, navigate to appropriate Client Appointment.
- Click Add Progress Note button.
- If there are no cases for this Client, a new Case will be created.
- If a Case has been created for this Client that you are not assigned to, a new one will be created.
- If there are multiple Cases you are assigned to, you will need to select appropriate Case.
Complete a Progress Note
Once the Note has been added, add the appropriate information to complete and Save the Note.
- The Appointment and Place of Service will auto-populate upon creation.
NOTE: If you have proper permissions you can change the Place of Service on the Note.
- The Duration In Minutes field autofills with the Appointment length. If it was shorter or longer, edit that here.
- The Provider(s) on the Appointment auto-fill. You can add/remove any Staff Member who is assigned to the Case or already on the Appointment.
- Enter Mental Status and Risk Assessment. Type in the field and select from list or enter in a new phrase.
- The Diagnostic Impressions from the Initial Assessment & Diagnostic Code tab and a History of Treatment Goals display. Click the Treatment Plan tab or the Initial Assessment & Diagnostic Codes tab to edit.
- As you fill in the Note, your draft auto-saves and will display a message in the top right corner.
NOTE: If you leave the page without pressing the green Save button, you can still retrieve the Note by clicking View Draft Copies of This Note. Loaded drafts disappear after the Note is saved.
- When you have completed the note click the green Save icon.
NOTE: There is no spell-check capability for Notes added at this time.