The administrator or the therapist assigned to the case can link progress notes to appointments.
Before You Begin
It is important that it be clear which notes and appointments are linked for key reasons:
- To transmit the proper CPT Code to an appointment
- For proper documentation and audit protection
- To account for clients with multiple appointments on the same day
- To prevent clients from rescheduling or canceling documented appointments
How Do You Know If a Progress Note is Linked to an Appointment?
- Agenda: The appointment will say "Edit Progress Note" instead of "add progress note"
- Calendar: You'll see a white paper icon on appointments with a linked progress note.
- Open up an appointment on the calendar: linked appointments are indicated by View Linked Progress Note hyperlink in the bottom right corner.
- Missing Progress Notes report will show you every appointment that does not have a linked progress note.
How to Link a New Progress Note to an Appointment
Scenario: Note has not been created yet
- From the agenda click the Add Progress Note button for the appointment you need to write a note for. It will ask if you want to add new, copy from last session (if there is a note from last session), or if you're subscribed to Wiley, to write a Wiley note.
- The appointment will pre-populate for you so you can complete the note and save as needed.
Scenario: Note has already been created but is not linked
- Navigate to the progress note that is not linked
- If the note has been signed you will not be able to edit. so the signature will need to be removed from the note to make edits or link the note to an appointment.
- Once the signature has been removed you may need to change the service date on the note to the date of service you wish to link it to. If it's already that date of service then no need to change.
- Click the appointment dropdown menu to pull up the appointment for that date of service. Select it from the dropdown.
If you don't see the right appointment in the dropdown menu on the note, please double-check the following:
- If note belongs to an individual client case, the appointment must be an individual client appointment for the same client. If note belongs to a group case, the appointment must belong to the same group.
- Dates of the note and appointment must be the same
- At least one staff assigned to the note must be assigned to the appointment
5. Click Save