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 basic information and, if desired, meta data.
• Learner Information: fields to input the learner’s basic information, such as name, diagnosis codes, insurance information, and, if desired, meta data. Click the toggles next to each field to turn them on and off.
  • 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, as well as any additional 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. Selecting the “Include Comments” checkbox allows providers to include comments in Session Notes and adds a “Comments Added During Session” section to the Session Summary.
• 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” pop-up allows users to customize fields included in preset sections by selecting the “Available Fields” tab. Users can add pre-existing Meta Data fields to the Learner Information and Provider Information sections using the “Meta Data” tab in the Configure Fields pop-up.

By default, the following fields are included in each preset section, but can be removed:

• Learner Information
  • Client first name
  • Client last name
  • Client date of birth
  • Insurance Information
  • Diagnosis Code
• Provider Information
  • Provider first name
  • Provider last name
  • Provider NPI #
  • Provider Credentials
• Appointment Information
  • Appointment date
  • Start Time
  • End Time
  • Duration
  • Billing Code
  • Units of Service
  • Service Address
  • Place of Service
• Signatures
  • Client Signature
  • Provider Signature

The following fields can be added with the “Configure Fields” pop-up: 

• Learner Information
  • Client ID
  • Client age
  • Secondary Insurance
  • Tertiary Insurance
  • Phone Number
  • E-mail
  • Gender
  • Guardian First Name
  • Guardian Last Name
• Provider Information
  • Provider ID
  • Phone Number
  • E-mail
  • Gender

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 gear  icon on the top right-hand side of the page to access the Session Note Template Settings:

• Dynamic Title: both text and preset fields can be used to create custom file names for the Files module.
• Footer: Click the toggle to add a footer to the session note template. Footers can include page numbers, client identifying information.
• Reasons for Edit: requires users to enter a reason for editing a signed session note from a timesheet.

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.

To utilize Session Note Templates in the Clinical module:

1. Reach out to your CR contact to enable the “Session Note Templates” feature
2. Assign Session Note Template and Session Notes permissions to the appropriate users.
3. Create Session Note Templates
4. Associate a Session Note Template to a service code and remove the existing session note from the “Note Templates” section. This will make the Session Note required for providers to complete during the appointment.
   • If the Session Note is not set to required, providers can complete the Session Note after ending the appointment. 
5. Schedule an appointment with the service code and complete any required Session Notes
6. Complete the appointment in CR Mobile
7. Complete any optional Session Notes in CR Mobile
8. View the session note on the web

Users with the following permissions have access to view, create, and delete session note templates, once the feature is enabled. These permissions can be enabled via the “Clinical” section of the Permissions module.

1. (Session Template > Access)
   • Provides users with access to the “Session Template” section.
2. (Session Template > Add New Templates)
   • Allows users to add new session templates.
3. (Session Template > Delete Templates)
   • Allows users to delete session templates.
4. (Service Code > Associate Templates)
   • Located in the “Billing” section. Ability to associate a session note template to a service code.

After creating session note templates, users will need Session Notes permissions to edit, add notes, delete, and unlock session notes.

The Session Note Templates permissions allow users to access, create, and delete templates. The following Session Notes permissions allow users to edit, modify, delete, and unlock session notes after the template has been created. These permissions can be enabled via the Learn section of the Permissions module and have been added and enabled to the “Admin” System permission group.

• (Session Notes > Add Note)
  • Ability to add a new session note.
• (Session Notes > Delete Note)
  • Ability to delete a session note.
• (Session Notes > Edit Note)
  • Ability to edit a session note.
• (Session Notes > Unlock)
  • Ability to unlock a session note after it has been added to a billing entry.
  • After unlocking and/or editing the session note, the provider and client signatures will be removed. New signatures can be captured and time stamped by the creator of the session note.

Users also need the (Billing > Manage Timesheets) permission to edit, delete, and unlock other users’ session notes. Without that permission, users can only perform those actions on their own session notes.