Creating Notes
- Add a progress note to a client session
- Supervision and signing off on a client's note
- Treatment plan progress
- Mental status exam
- Medications
- Psychotherapy notes
- Client contact notes
- Administrative notes
- Clinical notes not tied to a client session
- Frequently asked questions
Add a progress note 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.
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, you can find the Load last note option. Clicking on that will load the previous note you signed.
You can also add any other documents or media to your sessions, such as a recording or assessment via the Attachment button found on the bottom of the note (Max file size is 10MB). You can also add Medications, along with a Mental Status Exam, by clicking on the corresponding button.
Once your notes are complete, click the Sign and 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 a progress note, the session note will indicate "Awaiting supervisor review." Then, the assigned supervisor will receive a new task item on their Home page under Needs Attention > Needs Signature panel for the pending co-signature.
Check out our Supervision: Notes and Treatment Plans article for more guidance on managing supervision notes.
Treatment plan progress
Treatment plan objectives will populate on the note if the treatment plan is active and the Use Integrated Goals feature is enabled on the template being used.
You may view the treatment plan by clicking View, then click Manage to edit if needed. You may add a status for each objective of the treatment plan as well as additional details.
If the client does not have an active treatment plan and you would like to add one to the note, in the Treatment Plan section of the note, click Set Up. Here, you will be directed to the Diagnosis & Treatment tab to + Add Treatment Plan.
Check out our Treatment Plans article for more guidance on managing treatment plans.
Mental status exam (MSE)
Sessions Health makes it easy to add a Mental Status Exam to any note. On bottom of the note, you can select the option to add a Mental Status Exam.
You can set the default to "All within normal limits," by checking the corresponding box.
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. At this time, custom entries do not carry over to the next session note.
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.
You may also view and Edit medications for a client under the Diagnosis & Treatment tab in the client's chart.
Psychotherapy notes
A Psychotherapy Note, sometimes referred to as Process Note, may be added to any appointment by clicking the Add Psychotherapy Note button below the signature section.
When the psychotherapy note is complete, click the Done button or simply close out of the appointment. The text will auto-save.
To edit a psychotherapy note, click the Edit text in the upper right corner of the note.
Any text that you enter into a psychotherapy note will only be visible to you or other practitioners and supervisors with access to the client's clinical records. It will not be exported as part of the clinical note.
Load from last note feature
After at least one psychotherapy note has been saved at the bottom of a progress note, the Load last note button will become available. When working on the next incomplete note, you can save time retyping repetitive details by clicking this button to instantly load the most recently submitted psychotherapy note in the client’s chart.
Note: Some U.S. states consider anything written about a client as part of the clinical record, including psychotherapy notes. Know what your state and country's laws are regarding psychotherapy 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-clinical 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 - Enter a custom title for the note
Sticky note - Pins important admin notes
Date & Time - time and date for of the note
Upload - upload Images, PDFs, ZIP Files, Word/Office Documents, Spreadsheets, Audio, Video, Plain Text files attachments (100MB max)
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, right-hand panel of the client's chart, along with 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.
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.
Note: Administrator or Forms Administrator access is needed to create a custom note template.
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.
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, prescription features?
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?
Yes, you may use the Discharge/Termination of Services system template as is, or customize it. Alternatively, you may create your own template and then select the desired 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.