You can create a progress note for any case you are assigned to.
You can create a note for any case.
Before You Begin
There are several different ways to access and add a note for a client. In this article we are going to focus on one workflow that's foolproof and the workflow we suggest which is linking a note to an appointment.
Add a Progress Note
- Be sure you have created an appointment for this client.
- On the agenda navigate to the appointment date if you're not there already.
- Click Add Progress note button for the appointment that needs a note.
- If a case has not been created for a client yet a new one will be and you'll automatically be placed on the progress note to be completed. If a client has multiple cases you are assigned to you TheraNest will ask which case you're writing a note for.
- The appointment and Place of Service will auto-populate. If you have proper permissions you can change the place of service on the note.
- The Duration In Minutes field will autofill with the appointment length. If it was shorter or longer you can edit that duration here.
- The provider(s) who were on that appointment will fill in. You can make changes to this section too however you cannot add a staff member who is not assigned to the case or is not on the appointment.
- When entering information into the Mental Status and Risk Assessment areas, you can type in the fields and select from the list that appears, or enter in a new phrase.
- You’ll notice that Diagnostic Impressions from the Initial Assessment & Diagnostic Code tab and a History of Treatment Goals also appear. You can add or edit these by clicking the Treatment Plan tab or the Initial Assessment & Diagnostic Codes tab.
- Once you start typing in the note, a message will appear in the top right corner letting you know that a draft is being saved. If you were to leave the page without pressing the green Save button at the top right, you can still retrieve the note by clicking "View Draft Copies of This Note". Loaded drafts disappear after the note is finally saved. Click here to read more about document drafts in TheraNest.
- When you have completed the note click the green Save icon.