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.

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, if you are creating a HCFA for the service, the CPT code. An administrator can change the details of any service, or add to the service list by choosing Preferences>Settings>Manage Groups.

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 the service 'Individual Treatment'. Data will fill the detail area below.

Duration Only vs. Duration and Actual Time: This is configurable in your group 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). Click the up arrow and then modify the time accordingly. If you have the duration and start time the end time will fill in automatically.

Location: The default location can be set in your group preferences. If you always see folk 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.

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: For other documents; i.e. Releases of Iinformation, ACTT Assessments, 90801's, etc., you would choose Client Detail from Top Menu and then the Reports TAB.