Add a Session Note from Client File

Session Notes are added from the Notes tab in the Client File and then linked to an Appointment. 

NOTE: Alternatively, you can create a Note from the Task List. Click here to learn how.

1. Click the My Clients tab in the navigation bar and open the appropriate Client.
2. Click the Notes tab.
3. Click the plus icon to add a Session Note.
   
   
   
   
4. Select Start Date/Time. If there is an Appointment near that time, you can select that Appointment to link the Session Note with the Appointment.
5. Select Appointment Details.
   

   NOTE: Start and End Date/Time and Location default from the Appointment.

6. Enter Mental Status.
7. Enter Risk Assessment.
8. Enter any Current Medications or Pharmacological History.
   

   NOTE: Information entered here will populate in future Notes so you can just make updates in the future.

9. Ensure a Diagnosis is entered. This defaults from the Client Clinical Information tab.
10. Enter Clinical Information (SOAP - Subjective, Objective, Assessment, Plan).
11. Click Save Note. Note will verify to ensure that all required fields are complete.
12. If there are errors, fix the required fields.
13. Click Sign & Lock Note to complete Note.