Session Note Templates

Learn / Session Note Templates Associating Service Codes with Session Note Templates

Users with access to the “Service Codes” section of the Billing module and the (Service Code > Associate Templates) permission can associate service codes to session note templates. Session note templates need to be associated with the service code(s) attached to an appointment.

To associate service codes to session note templates:

  1. Navigate to the Billing module and select Service Codes
  2. Choose a service code
  3. Click the Associate Templates tab
  4. Click the + on the right-hand side and select the New Template drop-down
  5. Choose a session note template from the list and in the “Optional” drop-down determine if the session note should be optional or required.
  6. Click Save
  7. Select the Note Templates tab and remove any existing session notes.
  8. Click Save

CR Mobile / Learn / Session Note Templates Completing Session Notes in CR Mobile

To complete Session Note Templates in CR Mobile:

  1. After completing an appointment, the “Session Notes” screen will display. Select a session note. A list of session notes grouped by service code will display. Session notes with a red asterisk (*) are required and need to be completed.
  2. Fill out the session note and click Save & Attach. In the “Are you sure you want to save & attach this note?” pop-up, click Save.

  3. After completing all required session notes, click Continue.
  4. In the “Appointment Details” screen select Confirm to add the session note to the completed appointment for users to view on the web.
  5. Click Confirm in the “Appointment Summary” screen. If the completed appointment has any exceptions, a draft timesheet will be created. The session note will then be located in the timesheet.

Please note, insurance information is required in authorizations to be viewed in Session Notes in CR Mobile.

Learn / Session Note Templates Creating a Custom Section in Session Note Templates

To add a custom section to a Session Note Template:

  1. When creating a session note template, select CUSTOM on the left-hand side
  2. Select Section Header to the right-hand side and enter the Section Name
  3. Enter an optional description under the title
  4. The following fields can be dragged into each section:
    • Text Fields: enter the Title or Question
    • Text Area: enter the Text Area Question
    • Single Select: enter the Single Select Title and then each Option #
    • Multiselect: enter the Question or Label and then each Option #
      • Users can preselect multi-select answers.
    • Yes/No: enter the title or question that has a yes or no response.
    • Number: enter a title or question that has a number response.
    • Date Picker: enter a Title or Question, for the provider to complete during the session.
    • Time Picker: enter the Title or Question and then enter either the time or click the clock icon and select a time for the session note.
    • Click here to learn more about fields in custom sections.
  5. Click the Required toggle to make the question required.
  6. Click + ADD NEW OPTION to add more options to “Single Select” and “Multiselect” fields.
  7. Click the up and down arrows to reorder the questions in the section or “Options” in “Single Select” and “Multiselect” fields.
  8. Click Save Template

 

Learn / Session Note Templates Creating a Session Note Template

To create a Session Note Template:

  1. Navigate to the Learn module, click Clinical, and select Session Note Templates
  2. Click +NEW TEMPLATE
  3. Enter a template name in the “ADD TEMPLATE” pop-up and click SAVE
    • Users can still edit the title once the session note has been created.
  4. Enter an optional description under the title
  5. On the left-hand side, select either Custom or Preset Sections
    • “Preset Sections” contains six sections: Provider Information, Learner Information, Appointment Details, Signature, Session Summary, and Company Header.
    • The “Custom” section allows users to add section headers. Within each section, users can then add text fields, multiple-choice questions, checkboxes, dates, and times.
  6. After adding a section, users can edit the title and questions

  7. Click the “up and down” arrows to reorder questions
  8. Client and provider signatures can be marked required or optional by selecting the toggle .

    • Users can add the option to collect an additional signature, by selecting +Add Additional Signature.
    • Please note, this is for the session note and not the appointment.
  9. Select Session Summary and add an optional description.
  10. Click Save Template

Learn / Session Note Templates Editing and Deleting Session Note Templates

To edit a Session Note Template:

  1. Navigate to the Learn module, click Clinical, and select Session Note Templates
  2. Search for a template by entering the name in the Search Templates… search bar or select from the list of session note templates. Each session note template will have a “Modified: date” to inform users when it was last updated.
  3. Click the template to edit the questions
    • To edit the title, click the ellipses (…) on the right-hand side and then Edit.

To delete a session note template:

  1. Navigate to the Learn module, click Clinical, and select Session Note Templates
  2. Search for a template by entering the name in the Search Templates… search bar, or click the ellipses (…) on the right-hand side.
  3. Click Delete

Learn / Session Note Templates Session Notes in Timesheets

Users with the (Session Notes > Add Note) permission can add session notes to timesheets.

To add session notes to timesheets:

  1. Navigate to the Billing module and select Timesheets
  2. Scroll to the right-hand side of a timesheet and click the gear icon under the “Options” column
  3. Select Edit Timesheet to be directed to the “Edit Timesheet” screen
  4. Under the “Session Notes” section, select either Create session note… or the session note template under the search bar

    • For users with the (Session Notes > Edit) permission, click the pencil icon to edit the attached session note. Users can also delete the session note by clicking the trash can icon.
    • Click Continue in the “Edit Session Note” pop-up to edit the locked note. Please note, editing a locked session note will remove any collected signatures.

    • Click Save & Close.
  5. After selecting a session note from the “Create session note” drop-down, edit the note to complete any missing fields.

    • Please note, if the Session Note includes a session summary, the date will default to the current date.
  6. Click Save & Close

Please note, insurance information in Session Notes will display the payor, plan, and subscriber number if the data is available in the authorization. If the insurance information is not in the authorization, session notes will match the information in timesheets.