Notes & Forms

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

Files / Notes & Forms Filtering for Signatures in the Files Module

If a Notes & Forms or Session Note template has a client, provider, and “other” signature field filled out, it can be filtered for.

To filter for Notes & Forms’ signatures in the Files module:

  1. Navigate to the Files module and select Files
  2. Click the funnel icon on the left-hand side to open the filters panel
  3. In the “Filters” tab, click the Signatures drop-down
  4. To filter for providers and clients, select:
    • Signed
      • By Me: will filter for all files that have a provider or “other” signature field assigned to your account.
      • By All: will filter for files that have all signature fields on the template filled out.
    • Not Signed
      • By Me: will filter for files that have a provider or “other” signature field assigned to you, but are not yet completed.
      • By All: will filter for files that have an incomplete signature field.
  5. To filter for signatures other than yours or your clients:
    • In the search bar at the top of the grid, type the name of a provider or client.
    • Scroll through the list until it says, “Signed by…” or “Not yet signed by…”

Notes & Forms How to Edit Notes & Forms in Contacts’ Profiles

The “Edit Note” pop-up allows users to modify “Notes & Forms” in users’ profiles. When selecting an existing unlocked note in a profile, the note will open and allow users to input information and make changes.

To edit a Note & Form in a user’s profile:

  1. Select a note from the user’s profile
  2. Make any desired edits to the “Provider,” “Payor,” and “Title,” sections in the note

  3. Once all changes to the note have been made, select one of the following options:
    • Preview: displays the note in a separate pop-up, in front of the “Edit Note” pop-up.
    • Save & Lock: saves and locks the note, and closes the pop-up.
    • Save: saves the note and keeps the pop-up open.
    • Save & Close: saves the note and closes the pop-up.
  4. If the user clicks Cancel, the “Unsaved Changes” pop-up will appear to alert users to save any edits.


    • From this pop-up, users can select:
      • Save: saves the note.
      • Discard Changes: closes the pop-up without saving any changes.
      • Cancel: closes the pop-up and returns the user to the “Edit Note” pop-up with unsaved changes.

Files / Notes & Forms How to Save Notes and Forms as a Word Document

Users can save unlocked Session Notes and Notes & Forms as Word Documents (.docx). 

To do so: 

  1. Navigate to the Files modules and select a note/form or session note file to view. 
    • If the file is unlocked and can be downloaded as a Word Document, a drop-down option will appear next to the Download File button. 
  2. Choose Microsoft Word (.docx). 
  3. Select Download File. 

Notes & Forms / Notes & Forms / Notes & Forms Templates / Billing / Service Codes How to use Service Code Session Notes and Notes & Forms Requirements

The “Note Templates” tab in a service code’s properties consolidates existing templates and allows users to view all “Required,” “At least one required,” and “Optional” Session Notes and Notes & Forms. 

To view/edit Session Notes and Notes & Forms associated with service codes: 

  1. Navigate to the Billing module and select Service codes. 
  2. Select a service code to view its properties and click the Note Templates tab. 
  3. Session Notes and Notes & Forms associated with the service code are designated as “Required,” “At least one required,” or “Optional” which will reflect in timesheets when employees use the designated service code. 
  4. Click the ellipses to remove a template or move it to another section. 

To add a new note template: 

  1. Select a note template from the dropdown or start typing a note template name. 
  2. “Optional” is selected by default and can be changed to “Required” or “At least one required” via the dropdown.  
  3. Click Add to add the note template to the service code. 

Notes & Forms Printing Multiple Notes & Forms Linked to Billing Entries

To print multiple Notes & Forms that are linked to billing entries:

  1. Navigate to the Billing module and select Billing
  2. Filter for the client, date range of the notes & forms, and for the timesheets that have files attached
    • To filter for timesheets with files attached, click on the  drop-down and select File(s) attached

3. Display “150” billing entries per page instead of 50, because only 150 entries can be printed with notes & forms at a time.

4. Select the entries on the grid by clicking the first checkbox on top of the grid to select all

5. Click the Actions drop-down and select Bulk-generate invoices

6. Click Activity Statement

7. Choose a location in the Send from drop-down and make sure the “Send To” field has the correct payor to display on the invoice.

8. Click Bulk-Generate Activity Statements

9. Click Click here to print your invoices

10. In the invoice, choose/edit what information should be shown in the columns on the left-hand side:

  • In the “Columns” tab, select Notes/Forms
  • The “Payments” tab includes all of the information associated with the billing entries. This is generally not included in this type of activity statement.
  • The “Other” tab contains miscellaneous information, such as client information, aside from the “Notes Location” drop-down.

 

11. Click Save Settings. Please note, “Save Settings” is based upon login.

    • i.e. When user A saves, and user B wants to generate the activity statement the same as user A, user B has to select/unselect the same checkboxes in each column. It will only appear saved when users log in and generate another activity statement.
      • It is recommended to designate a team member to do this for the organization, for consistency. To designate more than one user, have them save the same settings in their log in.

12. Click Generate PDF. The notes & forms will not show in the preview of the invoice, they will appear once the PDF is generated and downloaded.

13. Click Download All and it will generate a PDF that can be printed.

14. After printing the PDFs, create a “Printed” billing label and assign it to those timesheets.

    • Navigate back to the billingmanager tab and select Back to billing
    • When printing more Notes & Forms linked to billing entries, exclude the “Printed” label from the grid.

 

Click here to learn how to change the location of notes in an invoice.

Notes & Forms Sharing a Note & Form with an Employee

To automatically share a Note & Form with an employee:

  1. In the Note & Form template, add a provider signature field
    • If there is not a provider signature field, the form will need to be manually shared with the employee.
  2. The signature field can be set to “optional,” so the form can still be saved without needing to obtain the signature. Once a note & form is signed, it is locked and cannot be edited, only necessary signatures can be obtained.
    • If the signature is required, the note & form will need to be signed by the provider, prior to saving.
  3. Please note, any user with access can edit the form until the provider signs and locks it.

Notes & Forms Sharing Notes & Forms with Clients

To automatically share a Note & Form with a client:

  1. In the Note & Form template, add a client signature field
  2. Set the signature to “optional,” so the note & form can still be saved without needing to obtain the signature. Once a note is signed, it is locked and cannot be edited, only necessary signatures can be obtained.
  3. Please note, clients and any user with access can edit the note until it is signed and locked by the provider. To prevent clients from editing the note, users can:
    • Lock the note
      • Once the note is locked, it cannot be unlocked or edited.
    • Share the note manually
    • Not include the client signature field

Notes & Forms Spacing in a Note & Form

When filling out a Note & Form, users can edit the spacing of a text box:

  1. If you are using the Rich text area box:
    • Select the Formats drop-down at the top of the form 
    • Click Inline and select Div

The text will be single-spaced.

Notes & Forms View Clients’ 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
    • In the client’s Dashboard, hover over the Notes & Forms widget and click the name of the form you want to view
    • Or, click Notes & Forms and select View all of “Client Name” Notes
      • If you do not have the Notes & Forms widget, click here to learn how to add a widget to the Dashboard
    • Or, to view all of the clients’ notes:
      • Click Profile on the top of the Dashboard
      • Click Notes & Forms
      • Click the form you want to view

Notes & Forms Create a Note from a 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
  3. In the client’s Dashboard, hover over the Notes & Forms widget and click Create a Note. If you do not have the Notes & Forms widget, click here to learn how to add a widget to the Dashboard
    • Or, click Profile on the top of the Dashboard
    • Click Notes & Forms
    • Click Add New 
  4. Click the template being used 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 grayed out and cannot 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 filling out all of the information in the form, and click any placeholders to add Progress Reports, Single List ReportActivitySession Summary, or to enter goals
    • If there is a signature included in the form, after the signature is entered, the form will be locked down and cannot be modified
  7. Click Save to save the information entered in the note and prevent editing the note later on
  8. Click Save and Lock to save the information entered in the note and prevent editing later on

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

Click here to learn how to create a client note from a timesheet.

Notes & Forms Create a Note from a Timesheet

To create a note for a client from a timesheet:

  1. Link a note template to a service code
  2. Navigate to the Scheduling module and select View My Calendar
  3. Click the lightning bolt icon on the appointment being converting
  4. Attach the note to the timesheet
    • Click New Note to complete a new note template
    • Click the select existing note pop-up to attach an existing note template
  5. Complete the note by completing all of the information in the form. Click any placeholders to add Progress Reports, the Single List Report, Activity, the Session Summary, or new client goals.
  6. Click Save

Notes created from a timesheet can be viewed and accessed by users connected to the client in the client’s profile in 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 is 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

Please 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 in to your account and sign from your personal computer, tablet, or phone at any time.

To do so:

  1. Navigate to the Billing module and select Timesheets
  2. Find the timesheet for the desired date/time of service and click the gear icon under the Options column on the right-hand side, then click Preview entry
  3. Select the Files tab, then click on the note you want to sign
  4. Click the Note/Form tab and then on your name under the signature field
  5. Type in your name and sign, using the mouse or touchscreen
  6. Click Continue
  7. Click Save or Save and Lock

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

Notes & Forms Create a Note with a Progress Report

The Progress Report placeholder in Notes & Forms Templates allows users to pull data in the note from the client’s learning tree, for any or all tiers in a goal. When creating a note with a Progress Report, 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 checkbox to select the targets to include in the note
    • Click the icon for each goal, to expand and select or deselect individual items 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 to report on
  4. Click Sort by to sort the goals by their status: 
    • In Progress  
    • Met
    • On Hold
    • Tree Index Order: displays goals in the order of branches in the learning tree
    • Date Edited: displays the most recently edited goals first
  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 can 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 checkbox  to select the goals you want to include in the note
  4. Click the start date and end date to enter the date ranges you want to report on
  5. Click Continue
  6. The goal 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 can 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

Click here to learn how to create a Note & Form Template with an Activity placeholder.

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, select the date of the session you are creating the note for, and all of 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 of 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 users to:

  • Add new goals
  • Select goals from the client, the organization, or your own library of goals
  • Report goal scores while creating a note

To create a Note & Form for a client that includes the Goal Creator placeholder, while creating a note from a Timesheet or 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 of the goals 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 of the goals created for your clients 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 of the organizations’ goals created by 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

    • Enter the Current Score for each goal
    • Click the + icon on left-hand side of each goal:
      • Goal Score: enter a score
      • Goal Status: click the 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. 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 the organization’s use, please contact a CentralReach Customer Support Specialist.

Notes & Forms / Billing / Notes & Forms Share Clients’ Notes & Forms

To share clients’ 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 want to share.
    • Or, click the funnel 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 want to share.
  4. Click the  Share Selected button on top of the files grid.
  5. Click  Specific Contact.
  6. Enter the name of the employee you want to share the notes and forms with.
  7. Click Share Files.

Notes & Forms / Billing / Notes & Forms View Clients’ Notes & Forms in the Insights Module

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

Once connected, clinical notes can be viewed from the Dashboard and Insights modules.

In the Insights module, clients’ notes assigned to timesheets can be viewed in bulk in the Service Audits report.

To generate a Service Audits report:

  1. Navigate to the Insights module and select Report Home.
  2. Click Client under Reports on the left-hand side and select Service Audits.
  3. Click to enter the:
    • Report start date
    • Report end date
    • Client name
    • Employee name
    • Service code
  4. Click the search  icon to generate the report.
  5. Notes will be included in the Clinical Notes column.
  6. Click to be redirected to the Files module to access the note.

Click here to learn how to connect employees to clients.

Click here to learn how to view notes and in the client’s Dashboard.

Notes & Forms Enable Notes & Forms Permissions

The organization account, or a user with the proper permission, can create or edit a custom permission group for employees 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
    • Click here to learn how to create a new custom permission group
  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 & Forms), 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 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.