Record a Progress Note 

 

You can record a Progress Note that is specifically related to an individual Patient Contact record using the process below.

 

You can access the Patient Contact record by going to: Patient -> Patient Contacts -> [select patient]. However, depending on the workflows your agency selects, the clinician may be able to access the desired Patient Contact record quickly by double-clicking the Appointment on the My Appointments widget.

 

Note: You must save your Patient Contact record prior to creating a Progress Note. 

 

  1. Click the Create Progress Note button 
  2. If your administrator has enabled multiple Progress Note templates, select the desired template from the list 
  3. If this is a new Progress Note template, the system will ask if you want to Load from an old record 
    1. Select Yes to copy an existing Progress Note
    2. Select No to use a blank template
  4. Enter the applicable information on each tab

    1. The Standard Progress Note template is shown above
    2. The Tx Planning tab allows you to load Goals from the Treatment Plan or manually enter new goals
  5. When complete, click the Sign  button next to your name 
  6. Enter your ClinicTracker password 
  7. Press Ok
  8. Press Save
    1. If you are setup to Never Require a Supervisor Signature, the Progress Note will be locked
    2. If you are setup to Always Require a Supervisor Signature, continue to Requesting a Supervisor Signature
    3. If you sometimes require a Supervisor Signature, you can select None Needed from the Supervisor drop-down , then click save to lock the Progress Note or, you can continue to Requesting a Supervisor Signature

 

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