Progress Note: Services

Purpose: To create a basic individual note. To become comfortable navigating the program.

If you have not done so, choose Add Note from the side menu and select a client from the client list by clicking on the arrow to the left of their name or choosing Forward from top menu.

You are presented with a list of services you provide. These are in three broad categories; Individual Treatment, Groups and Service Plan. Group selections must have the word 'Group' in the Service Name e.g., Relapse Prevention Group, Coping Skills Group, Grief Group.etc.

Select a row, the background will turn blue, and the detail area fills with the Service Name, Service ID, Duration, and Location for that service. Change the Duration by clicking on the arrow to the right of the field. The Service ID can be your practice's designation or a CPT code. A Supervisor can change the details of any service, or add to the service list by choosing Preferences>Settings>Manage Groups (See Supervisor Tutorials).

Other top menu buttons allow you to (from left to right) 1) go to the client's details 2) change the date of the note and 3) read the help file on this layout.

For purposes of this tutorial choose an 'Individual Treatment' service. Data will fill the detail area below.

Duration Only vs. Duration and Actual Time: This is configurable in your settings. Some practitioners only need the Duration field to reflect time spent with this client and can set their group settings to Duration Only and never see the Start Time/End Time fields. Choose the duration here or wait until previewing the note and change it there using the 'Wrench' button.
Other clinicians want to put the actual time they were with the client on the note; i.e. 46 minutes (1:30 PM - 2:16 PM). There are start and end time fields in the detail area as in the image above. WHen you click into one of those fields it will put the current time. You can move the numbers around by clicking into the hour or minute field and using the up and down arrows on your keyboard, or the little arrows to the right of the fields, to get the start time you want. If you have the duration and start time the end time will fill in automatically.

Location: The default location can be set in your preferences. If you always see cleints in your office, or always see them in their homes then that choice can be set as the default and you only need to change it when something extraordinary happens and you see them in a non standard location. Clicking on any of the lsbels; e.g. 1 Office/Cotract Agency, will change the number and location info.

You now have the client's name, the service, the date, the duration (optionally the time) and location... choose the arrow beside the service, or the Forward button to continue the note.

Please view the Video Tutorial Basic Note for further information on this layout.

ASIDE: To begin creating other documents; i.e. Releases of Information, 90801's, etc., click the Client Detail button in the top menu to get to the Client Detail area (where you entered their demographics), and open the last TAB 'Reports'. Choose from the list of available documents by clicking the arrow on left side of row.