Session Note Templates allow users to input all necessary information regarding learners’ progress in programs and indicate if any adjustments should be made to their treatment plans once a session has been completed.
Users can name session note templates, add a description, and create sections with required or optional fields. In the sidebar on the left-hand side, users can input either preset or custom sections in session note templates, as well as headers and footers.
There are six sections in the “Preset Sections” tab:
- Provider Information: fields to input the provider’s full name, phone number, and NPI.
- Learner Information: fields to input the learner’s full name, phone number, date of birth, diagnosis codes, and insurance information. Click the toggles next to each field to make them required.
- Please note, when completing session notes from CR Mobile, authorized codes are required for the diagnosis code and insurance information fields. Authorized codes pull from the authorization, whereas unauthorized codes pull from the client’s claim settings.
- Appointment Details: fields for the appointment date, start and end times, duration, billing code, units, Place of Service, and service location.
- Signatures: fields for the client and provider signatures. Click the toggles next to each signature to indicate if the signatures are required.
- Session Summary: fields for the title and description of the session summary. Click the toggle to make the session summary required.
- Company Header: adds organization logos to the top of session note templates. Logos must be JPG or PNG files with a maximum size of 20 MB, 250px in width, and 100px in height.
All preset sections, except the “Session Summary” and “Company Header” sections, can be edited using the “Configure Fields” button. The “Configure Fields” button allows users to customize fields included in preset sections. By default, the following fields are included in each preset section, but can be removed:
- Learner Information
- Client first name
- Client last name
- Client ID
- Client date of birth
- Client age
- Insurance Information
- Phone Number
- Diagnosis Code
- Guardian First Name
- Guardian Last Name
- Provider Information
- Provider first name
- Provider last name
- Provider ID
- Provider NPI #
- Phone Number
- Appointment Information
- Appointment date
- Start Time
- End Time
- Billing Code
- Units of Service
- Service Address
- Place of Service
- Client Signature
- Provider Signature
The “Custom” tab allows users to create custom sessions by clicking Section Header. The custom section can then be named with an optional description. Within custom sections, users can drag the following required or optional types of fields into the template:
- Text Fields: a question or prompt that is answered with a short, open-ended response.
- Text Area: a question or prompt that is answered with a long, open-ended response.
- Single Select: a multiple-choice question or prompt. Users can select a single bullet from the list of options.
- Multiselect: a question or prompt that is completed by clicking one or more of the checkboxes.
- Yes/No: a question or prompt that is answered with a yes or no.
- Number: a question or prompt that is answered with a numerical response.
- Date Picker: a date selected for the session note.
- Time Picker: a time selected for the session note.
The “Single Select” and “Multiselect” fields can be further customized by clicking:
- The toggles to make each field required or optional.
- + Add New Option to add more options to each field.
- The up and down arrows to reorder the options within the field.
- The trash can icon to delete the option.
Click the Include on template toggle to add a footer to the session note template. Footers can include page numbers, client identifying information, and any reasons for session note edits.
Please note, insurance information in Session Notes will now 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. Insurance information is required in authorizations to be viewed in Session Notes in CR Mobile.
Click here to learn how to add custom sections to Session Note Templates.