Once the appointment time has passed, your finished appointment will show up in your Needs Attention list on your Home page and the client's record on the right side scroll area.
Clicking on the past appointment will open the appointment notes interface.
We offer seven note templates you can add to your account from the Forms & Documents > Forms > System Forms page:
Simple Note
BIRP Note
Client Progress Note
DAP Note
Discharge/Termination of Services Note
EMDR Progress Note
Group Therapy Progress Note
SOAP Note
You may also create your own custom note template in the Forms & Documents > Forms > My Forms page in the Notes section.
If you signed a previous note for a client and you are using the same note template, a Load from previous note option will appear. Clicking on that will load the previous note you signed.
Simple Note template
You can also add any other documents or media to your sessions, such as a recording or assessment via the Upload button. (Max file size is 10MB)
Upload Attachement
Once your notes are complete, click the Sign as Complete button. You will be presented with the signature modal. By typing your full name in this form, you acknowledge that you are providing your name to be used as an electronic representation of your signature and that all information entered is accurate and complete.
Signing a note
Supervision and signing off on client notes
If a practitioner is assigned a supervisor, after the supervised practitioner signs a progress note, the session note will indicate "Awaiting supervisor review."
Awaiting supervisor review
The supervisor will then see the incomplete note in the Needs Attention area of their Home page with a link to the note to review and sign. If something needs to be modified in the note, the supervisor may "unlock" the note. This action will display the incomplete note in the Needs Attention area of the supervisee's Home page.
Supervisor signature
We recommend the supervisor add notes for the supervisee in the Process Notes section. The Supervisee can then review the supervisor's note, modify the existing client note, and sign the note again for the supervisor's review and sign-off.
Cancelling an appointment
To cancel an appointment, open the appointment. If you're in the popup view of the appointment, you can cancel by clicking the Cancel icon in at the top of the note.
Cancel icon
If you're in the expanded appointment view, click "..." then Cancel Appointment.
Cancel from the option menu
Or click on the drop-down from the Sign and Complete section, then select Cancel Appointment.
Cancel appointment
You will be presented with a modal asking for information on the cancelation, and if your Practice has a cancelation fee setup, you will see that here. If your Practice allows for the fee to be overridden, you can enter a new canceled appointment fee here.
Once a treatment plan has been created, you may add details to each case note regarding progress. You will find this section just below the clinical note section.
You may view the treatment plan by clicking the eye icon. You may add a status for each objective of the treatment plan as well as additional details. From this section, you may also include the interventions used by selecting from the dropdown or adding your own interventions.
Sessions Health makes it easy to add medications to your clients records. On the note screen, you may add medications near the end of the note above the signature link.
Add medications
You may view and edit medications for a client by going to the client details screen and then selecting the Diagnosis & Treatment tab. You will find medications near the bottom of the screen.
You may add process notes to any case note using the Process Notes section. It is at the bottom of the clinical note.
Any text that you enter here will only be visible to you. It will not be exported as part of the clinical note. To view the process note, return to the note details screen for any appointment.
Note: Some states consider anything written about a client part of the clinical record. Know what your state and country's laws are regarding process notes.
Client contact notes are integrated with the calendar. You may click the calendar at the date and time of the contact and then select Client Contact from the dropdown. You will be prompted to fill out some fields and then enter the details of your note.
Client contact note
After creation, the calendar will display two tabs, the Details tab contains the summary of the contact and the Notes tab contains the content of the note. You may also upload any attachments related to the client contact event.
Sometimes, admins or other clinicians may need to add a non-clinicial note about a client. On the client record page, select the Summary tab. Click the +Add button and select Administrative Note from the dropdown.
Administrative note
You will be presented with a modal to create the note.
Administrative note
Title - the title for this note
Sticky note - pin and highlight this note?
Date & Time - time and date for this note
Upload - upload any attachments
Once you have added your Administrative note, it will appear in the Summary tab for that client.
Sticky notes
Make an Administrative note sticky to pin it to the top of the client's chart, at the top of the client's Summary tab, and on the bottom of the appointment popup.
Note: There's no limit to the number of sticky notes a client can have, but the most recent one will always display first.
Clinicians may need to add a clinical note such as a termination or discharge note where there may not be a client session to tie it to. To add one, go to the client's Summary tab. Click the +Add button and select Clinical Note from the dropdown.
Adding a Clinical Note not tied to a session
From there, you can name the clinical note, mark the date and time, and select a note template. You can choose from any of your notes templates or create your own custom note template in the Forms & Documents > My Forms > Notes section.
How do I customize interventions and mental status exam options?
We provide a large set of options under mental status exam sections and interventions on notes and treatment plans. However, you may still add your own items in any of these dropdown. Simply type in your custom item and press ',' when you are finished. While these options won't persist (a feature we may add in the future) it does allow you to add your own custom interventions and mental status exam characteristics.
How do I print notes, treatment plans, etc.?
Notes, treatment plans and other important documents are easily downloaded in PDF format to print. To download a document, click the '...' menu on any document that supports downloading. Click Download to download a PDF for printing.
Download / print treatment plan
Does your platform offer dictation?
Many people use dictation for clinical notes and other documentation in Sessions Health. While the platform itself doesn't contain a dictation feature, the device you use likely does. If you have a PC, you may click the Windows button + H to launch speech services. If you have a mac, follow the instruction in this Dictate messages and documents on Mac article. If you have an iPhone, see this Dictation text on iPhone article.
Do you offer e-Prescribing, prescribing, eprescribing, prescriptionfeatures?
We currently do not have e-prescribing or ordering of labs features. However, we continually add new features and may add these in the future.
Do you have a discharge summary template?
We don't have a template for discharge summaries, but you may create your own template and then select this template when creating a Clinical Note from the client's Summary tab. Please see the Custom Forms Tutorial for details on creating your own forms.
