Creating Notes
- Add notes to a client session
- Treatment plan progress
- Mental status exam
- Medications
- Process notes
- Client contact notes
- Administrative notes
- Clinical notes not tied to a client session
- Frequently asked questions
Add notes to a client session
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.
By default, you can add five types of notes: Simple Note, BIRP Note, Client Progress Note, DAP Note, EMDR Progress Note, and SOAP Note. You may also create your own custom note template in the Forms & Documents > My Forms > Notes section.
For more information on the DAP and SOAP format, please read here: https://www.goodtherapy.org/blog/psychpedia/psychotherapy-notes
If desired, you can load your notes from the previous session by clicking on Load from previous note.
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)
Once your notes are complete, click the Mark 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.
Supervision and signing off on client notes
If a practitioner is assigned a supervisor, after the supervised practitioner signs the note, the session note will indicate "Awaiting supervisor review."
The supervisor will then see the incomplete notes in the Needs Attention area of their Home page with a link to the note. If something needs to be modified in the note, the supervisor may "unlock" the note. This will display the incomplete note in the Needs Attention area of the supervisee's Home page.
We recommend the supervisor add notes for the supervisee in the Process Notes section. The Supervisee can review those notes, modify the existing client notes, and sign the notes again for the supervisor's review and sign-off.
Cancelling an appointment
From the Mark as Complete dropdown, you can also cancel the 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.
For more information on how to bill for cancelled appointments, see our How to bill for a no-show, missed, or late-cancel appointment article.
Treatment plan progress
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.
Mental status exam (MSE)
Sessions Health makes it easy to add a Mental Status Exam to any note. On the note screen, select the option to Add Mental Status Exam.
To set the defaults to "All within normal limits," select the three dot control.
Now you may customize each section with either options from the drop-down, or by adding your own.
Note: If adding your own, add a comma after each custom item to add it.
Risk Assessment
The Risk Assessment is part of the Mental Status Exam and is found at the tail of assessment.
Medications
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.
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.
Process notes
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 note
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.
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.
Administrative notes
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.
You will be presented with a modal to create the 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.
Sticky note at the top of the client's chart
Sticky note at the top of the client Summary tab
Sticky note on the appointment popup
Clinical notes not tied to a client session
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.
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.
FAQ
Do you provide drop-downs of Mental Health ICD diagnoses to choose from?
When assigning a diagnosis, we have an auto-suggest dropdown of ICD codes available. Our system strictly uses ICD-10 codes and descriptors.
Can clients be sent treatment plans to electronically sign?
Yes. Please see Sharing Treatment Plans With Clients for more details.
Can clients be sent assessments to fill out through the client portal?
Yes. Please see Sharing Assessments With Clients for more details.
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.
Do you offer e-Prescribing, prescribing, eprescribing, prescription features?
We currently do not have any features used by medical doctors or psychiatrists for prescribing medications.
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.