Notes & Forms

Learn how to create and manage Notes & Forms Templates and how to create client's clinical notes.

Notes & Forms View Client’s Notes & Forms

To view a client’s notes & forms:

  1. Navigate to the  Contacts module and select Clients
  2. Click the name of the client you want to view notes for
    1. In the client’s Dashboard, hover over the Notes & Forms widget and click the name of the form you would like to view or click Notes & Forms and select View all “Client Name” Notes
      1. If you don’t have the Notes & Forms widget, click here to learn how to add a widget to the Dashboard
    2. Alternatively, to view all the client’s notes, click Profile on the top of the Dashboard
      1. Click Notes & Forms
      2. Click the form you would like to view

Notes & Forms Create a Note from the Client’s Dashboard

To add a client note from the client’s Dashboard:

  1. Navigate to the  Contacts module and select Clients
  2. Click the name of the client you are creating a note for
  3. In the client’s Dashboard, hover over the Notes & Forms widget and click Create a Note. If you don’t have the Notes & Forms widget, click here to learn how to add a widget to the Dashboard.
    • Alternatively, click Profile on the top of the Dashboard
    • Click Notes & Forms
    • Click Add New 
  4. Click the template you are using to create the note
    • Use the toggles or the search bar to find the template
    • Templates created with appointment or service codes dynamic fields, are greyed out and can’t be created from the client’s Dashboard. These templates can only be used to create notes in a Timesheet.
  5. If prompted, enter the Provider name, the new form Title, select a Payor or any other information requested and click a section in Choose a Section to start completing the form
    • If the form has multiple sections, click Next to go to the next page
  6. Complete the note by clicking and filling out all the information in the form, and click any placeholders to add Progress Reports, Single List Report, Activity, Session Summary or to enter goals
    1. If there is a signature included in the form after the signature is entered the form will be locked down and can’t be modified
  7. Click Save to save the information entered in the note and be able to continue editing the note later on
  8. Click Save and Lock to save the information entered in the note and not be able to edit later on

Please note that to create a client note directly from the client’s Dashboard, the user must be connected to the client and must have permission to access notes.

To learn how to create a client note from a timesheet, click here.

Notes & Forms Create a Note from a Timesheet

To create a session note from a Timesheet, you must first link your service codes to Notes & Forms Templates. Once the codes are linked to the template, to create a note for a client from a timesheet:

  1. Navigate to the Scheduling module and select View My Calendar
  2. Click the lightning bolt  icon on the appointment you are converting
  3. Scroll down to the bottom of the timesheet, to the Notes section and click:
    1. New Form: to fill out a brand new form template, from scratch
    2. Select Form: to select and continue filling out a form you have already started completing for this client’s session
  4. Complete the note by clicking and filling out all the information in the form, and click any placeholders to add Progress Reports, Single List ReportActivitySession Summary or to enter new client goals.
  5. Click Save

Notes created from a timesheet can be viewed and accessed by users connected to the client in the client’s profile within their Dashboard, in the  Billing module within the converted timesheet and in the Files module.

Notes & Forms Sign a Note Attached to a Timesheet

Providers can sign notes/forms attached to a timesheet during conversion. If the “Allow signature from provider accounts” setting enabled within the note template, both the provider and client can sign from the provider’s account. To sign a note from a timesheet:

  1. Click on a signature field within the note
  2. Type in your name and sign using the mouse or touchscreen
  3. Click Continue

Note: When a client or provider signs a note it becomes locked. This means the note can no longer be edited. Any empty signature fields can still be signed.

If you did not sign a note/form during conversion, providers and clients can both sign from their own accounts. This means that if you forget to sign during the session, you can log into your account and sign from your personal computer, tablet, or phone at any time. To do so:

  1. Navigate to  Billing module and select Timesheets
  2. Find the timesheet for the desired date/time of service and click the Options  button to the far right, then click Preview
  3. Select the Files tab, then click on the note you wish to sign
  4. Click the Note/Form tab and click on the signature field you wish to sign
  5. Type in your name and sign using the mouse or touchscreen
  6. Click Continue

Note: If you know the name of the note, you can also search for it within the Files module.

Notes & Forms Create a Note with a Progress Report

The Progress Report placeholder in Notes & Forms Templates allows you to pull data in the note from the client’s Learning Tree for any or all tiers in a goal. When you are creating a note with a Progress Report, you will be able to select any tiers from the Long Term Goal, the Short Term Goal, a Target, or any combination of all three as configured in the template.

To create a Note & Form for a client that includes a Progress Report, while creating the note from a Timesheet or from the client’s  Dashboard:

  1. Click Select Goals for Progress Report
  2. Click the checkboxes to select the targets you would like to include in the note
    • Click the  icon for each goal, to expand and select or unselect individual items you would like to exclude or include from the report, and select the types of graphs to include, if any, as defined on the template
  3. Click the start date and end date on the top to enter the date ranges you would like to report on
  4. Click Sort by to sort the goals by their status: In Progress, Met, On Hold, Tree Index Order, Date Edited
  5. Click the calendar icon within the goals selected to set the data point range override for each goal
  6. Click Continue
  7. The list of targets and all the details as defined in the template will be displayed on the note

Notes & Forms Create a Note with a Single List Report

The Single List Report in a Note & Form Template allows you to pull data in the note from the client’s Learning Tree for one single tier. When you are creating a note with a Single List Report, you will be able to select one Short Term goal, one Long Term goal or one Target, but not all three at once.

To create a Note & Form for a client that includes a Single List Report, while creating the note from a Timesheet or from the client’s  Dashboard:

  1. Click Select Learn Goal
  2. Click the tab from where you want to pull information from: Short Term, Long Term or Target
  3. Click the checkboxes to select the goals you would like to include in the note
  4. Click the start date and end date to enter the date ranges you would like to report on
  5. Click Continue
  6. The gaol information details will be displayed on the note

Notes & Forms Create a Note with Activity

The Learn Activity placeholder in a Note & Form Template, allows you to pull data in the note from the client’s Session Summary. When creating a note that includes this placeholder you will be able to select one by one, the Session Summary targets you want to include in the note. Once selected, the Session Summary Branch Name, Current Data Point, Added By and the date when the data point was collected in the client’s Data Sheet will be displayed on the note in a list format.

To create a Note & Form for a client that includes a Learn Activity placeholder, while creating the note from a Timesheet or from the client’s  Dashboard:

  1. Click Select Learn Activity
  2. Click the date field to select the date of the session you want to pull activity from
  3. Click to select all the targets you want to add to the note
  4. Click Continue
  5. The list of targets and all the details will be displayed on the note

To learn how to create a Note & Form Template with an Activity placeholder, click here.

Notes & Forms Create a Note with Session Summary

The Session Summary placeholder in a Note & Form Template pulls data in the note from a session in a table format. When creating a note with Session Summary, you will be able to select the date of the Session you are creating the note for and all the client’s goals from the Session Summary will be added to the note.

To create a Note & Form for a client that includes a Session Summary, while creating the note from a Timesheet or from the client’s  Dashboard:

  1. Click Select Session Summary
  2. Click the date field to select the date of the session you want to pull information from
  3. Click the checkbox  of the Session you want to pull information from
  4. Click Continue
  5. The list of targets and all the details from the Session Summary will be added to the note in table format

Notes & Forms Create a Note with Goals

The Goal Creator* placeholder in Notes & Forms allows you to dynamically add new goals, select from the client, the organization or your own library of goals, and also report goal scores while you are creating a note.

To create a Note & Form for a client that includes the Goal Creator placeholder, while creating the note from a Timesheet or from the client’s  Dashboard:

  1. Click Select Goals for Goal Creator
  2. Select Goals: click the drop-down under each section to select the goals to be added to the note
    • “Client Name” Goals: lists all the goals you have already created for this client
      • Click the checkbox to select the client’s goals to be added to the note
    • “User Name” Goal Library: lists all the goals you have created for all your client’s in CentralReach
      • Click the  icon next to the client’s name to expand their library of goals
      • Click the checkbox to select the goals to be added to the note
    • “Organization Name” Goal Library: lists all the organizations’ goals, created by all the organization’s users or employees
      • Click the  icon next to the client’s name to expand their library of goals, and continue to click the  icon to continue to expand as necessary
      • Click the checkbox to select the goals to be added to the note
    •   Add custom goals…: create brand new goals for the client
      • Add the goal name
  3. Click Continue

      

4. Enter Score & Data: enter the scores for all the goals added to the note

  • Click to enter the Current Score for each goal
  • Click the + icon on left hand-side of each goal:
    • Goal Score: click to enter a score
    • Goal Status: click drop-down to select goal status
    • Note: click Add a Note… to add notes about this goal
  • Goals with toggle view available will be identified with an  icon. Click it to view and edit scores.
  • If new goals were added for the client in step 2 above, if prompted, click the Data Type drop-down to select goal data type

5. Click Continue

6. All goals will be added to the client’s Learning Tree.

  • If a new goal was created in the note, click the drop-downs to select the Learning Tree and the branch where the new goal has to be placed

*Goal Creator is a premium Note & Form feature. To learn more about this feature and turn it on for your organization’s use, please contact your CentralReach Customer Support Specialist.

Notes & Forms / Billing / Notes & Forms Share Client’s Notes & Forms

To share client’s notes & forms with another employee connected to the client:

  1. Navigate to the Files Module  and select All Files
  2. Search for the file you would like to share
    • Alternatively, click the filter  icon to expand the left hand-side menu with Labels, Filters and Templates
    • Click the Filters tab
    • Click  File Details
    • Click Choose  next to File Type and select Notes and Forms
  3. Click to enter a checkmark in the box  on the left of the files you would like to share
  4. Click the  Share Selected button that appeared on top of the files grid
  5. Click  Specific Contact
  6. Enter the name of the employee you would like to share the notes and forms with
  7. Click Share Files

Notes & Forms / Billing / Notes & Forms View Client’s Notes & Forms in Reporting Module

To be able to view client’s clinical notes, you must first be connected to the client.

Once connected, clinical notes can be viewed from the Dashboard Module  and the Reporting Module .

In the Reporting Module client’s notes assigned to timehseets can be viewed in bulk within the Service Audits. 

To generate a Service Audits report:

  1. Navigate to the Reporting Module  and select Report Home
  2. Scroll down to the Client section and click Service Audits
  3. Click to enter the report start date
  4. Click to enter the report end date
  5. Click to enter the client name
  6. Click to enter the employee name
  7. Click to enter the service code
  8. Click the search  button to generate the report
  9. Notes will be included in the Clinical Notes column. Click to be redirected to the files module to access the note.

To learn how to connect employees to clients, click here. 

To learn how to view notes and in the client’s Dashboard, click here.

Notes & Forms Enable Notes & Forms Permissions

The organization account, or a user with the proper permission, is able to create or edit a custom permission group for employees to be able to create clinical notes for clients or to manage the creation of Notes & Forms Templates for the organization.

To provide employees permissions to access or manage Notes & Forms:

  1. Navigate to the  Permissions module
  2. Select the permission group you want to provide Notes & Forms access to or create a new group for this permission
    • To learn how to create a new custom permission group, click here
  3. Click the Permissions tab
  4. Click Notes & Forms Templates
    • To grant employees in the group access to create clinical notes for clients or providers, using the organization’s notes and forms templates, click the x gray button on the right hand-side of Access, to turn it into a green checkmark
    • To grant employees in the group access to manage and create notes and forms templates for the organization, click the x gray button on the right hand-side of Manage>Notes & Formsto turn it into a green checkmark
    • To grant employees in the group access to manage and create notes and forms templates for the organization with the Goal Creator option within Learn, click the x gray button on the right hand-side of  Notes > Goal Creator to turn it into a green checkmark

To remove the Notes & Forms Templates permissions from a group, click the green checkmark to turn it into an x gray button.