Progress Notes

Patient -> Patient Contacts -> Appointment tab

 

Just like attaching a medication to an Appointment record, you can also link a Progress Note.

 

  1. An icon Note16 next to the Progress Note button indicates a Progress Note exists for the current appointment.
  2. Press this button to view or enter a Progress Note. The note type will also be displayed in the Treatment History Box on the bottom of the form.
  3. An asterisk next to the note type in this list indicates a locked record, with all signatures entered.

 

Note:  You will not be able to click this button until you have entered all required fields, because the main Patient Contact Record needs to exist before you can attach items such as Medications or Progress Notes.

 

Progress Note Formats

Seven different Progress Note formats can be selected through the Options form, Formats Tab. The available formats are:

 

  1. Standard: ClinicTracker’s built-in default format.
  2. Free-Form: Free-text note for clinical impressions.
  3. Specialty: Designed for subspecialty programs that focus heavily on mental status and treatment planning.
  4. SOAP: Subjective, Objective, Assessment, Plan.
  5. DAP: Data, Assessment, Plan.
  6. SNAP:  Strengths, Needs, Abilities and Preferences.
  7. Personal Therapy: This template follows the same format as the DAP note, but allows you custom label and further customize an additional Progress Note template

 

While each of the formats has different elements, certain sections are consistent across all of the formats as described below.

 

Treatment Planning

To meet many regulations, each Progress Note must make mention of how the Treatment Plan was addressed in the current session.

 

The tab labeled Tx Planning prompts you to perform this function.

 

There are dropdowns for Goals and Objectives as well as one for notes.

 

You may manually select these goals and objectives from the available list, or load them from the most recent Treatment Plan by clicking the Pick From Tx Plan button. This will bring up a form with the goal/objective pairs from the most recent Treatment Plan for the current patient. Double-clicking an item in the list will load the goal and objective back in the Progress Note Form. The From Treatment Plan box will also be checked to indicate that the noted goal and objective were pulled directly from the Treatment Plan.

 

Note: Only active goals/objectives will be displayed as options when using the Pick From Tx Plan button. As a result, any goal/objective with an achieved date entered will not be displayed in the list.

If you will be entering a goal and objective that is recorded in the Treatment Plan, it is recommended to select it using the Pick From Tx Plan option. This will allow you to generate accurate data in the Progress Note Treatment Plan Linking Report located at Admin Reports -> Clinic Productivity.

 

 

Psychotherapy Notes

You may want to include information in your notes that you want to keep separate from the formal medical record (what HIPAA calls the “designated record set”). According to our best information, Psychotherapy Notes receive a special legal status that make them more challenging to subpoena.

 

The top of the form has a disclaimer that reads, “This space is for psychotherapy notes and is not part of the designated record set.  Do not file this document in the patient's medical record.” To further help with privacy, the secure section will not be printed out with the rest of the Progress Note; it has its own separate print routine. You may print Psychotherapy Notes by clicking the icon.

 

 

Note: We cannot guarantee that this extra separation of Psychotherapy Notes will provide the legal protection you are seeking. Please check with your attorney for clarification.

 

Current Medications

Each progress note template contains a section labeled Current Medications.

 

This box allows you the opportunity to note all medications the patient is taking. While you can type this section in by hand, you are also given the option to load data that you have entered in the patient’s Medication Record.

 

 

To do so, place the mouse cursor where you want the text inserted, and click the Import From Med History button.

 

The list that displays will contain all medications recorded for the patient within the last 60 days. If you wish to extend this range, change the number of days in the textbox on the top of the form, and click the refresh button to the right.

 

 

Place a checkmark in the first column of each medication you would like to include in the Current Medications section and hit Select. The prescription date, medication name, and dosage will be filled in automatically.

 

 

 

Paperwork Notifications

When completing a note, you have the option to send a signature reminder to your supervisor, and he/she has the option to return one back to you. You can access this feature by clicking the icon on the top toolbar. For more information, see the section on Sending Paperwork Notifications.

 

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