Session Note Templates

Learn / Session Note Templates Session Note Templates

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 two types of sections in session note templates.

The “Preset Sections” tab contains six sections:

  • Signatures: fields for the client and provider signatures. Click the toggles next to each signature to indicate if the signatures are required.
  • Provider Information Section: fields to input the provider’s full name, phone number, and NPI.
  • Appointment Information Section: fields for the appointment date, start and end times, duration, billing code, units, Place of Service, and service location.
  • Learner Information Section: 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.
  • 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 for the “Session Summary” and “Company Header” sections, can be edited using the “Configure Fields” button. The “Configure Fields” button allows users to customize fields to include 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 date of birth
    • Insurance Information
  • 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 “Custom” tab allows users to create custom sections 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 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 response.
  • 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.

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 information in timesheets. Insurance information is required in authorizations to be viewed in Session Notes in CR Mobile.

Click here to learn how to create a Session Note Template.
Click here to learn how to add custom sections to Session Note Templates.

Learn / Session Note Templates Session Note Templates Checklist

To utilize Session Note Templates in the Learn 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. 
  5. Schedule an appointment with the service code
  6. Complete the appointment in CR Mobile
  7. Complete the session note in CR Mobile
  8. View the session note on the web

Learn / Session Note Templates Session Note Templates Permissions

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 “Learn” 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.

Learn / Session Note Templates Session Notes Permissions

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.

CR Mobile / Learn / Session Note Templates The Session Notes Workflow on CR Mobile

Session Note Templates are created in CentralReach and attached to appointments that need to be completed in the premium version of CR Mobile. The following workflow should be completed:

  1. CR Mobile users with the appropriate Session Note Template and Session Notes permissions, and access to the Learn module in CR can create a session note template on the web.
  2. Associate the session note template to the service code
  3. Schedule an appointment and include the service code
  4. Complete the appointment in CR Mobile
  5. Complete the session note in CR Mobile
  6. View the session note in CentralReach
    • For users completing Electronic Visit Verification (EVV) appointments, any exceptions will be included in a draft timesheet.