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 to attach them 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 Note Templates tab.
4. Select a note template from the dropdown or enter a note template name in the search bar.
5. “Optional” is selected by default and can be changed to “Required” or “At least one required” via the dropdown.
6. Click Add to add the note template to the service code.
7. Click Save or Save & Add Another to add another note template to the selected service code.

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
   

To create a Session Note Template:

1. Navigate to the Clinical module 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, add Preset Sections. The “Preset Sections” contains six sections: Provider Information, Learner Information, Appointment Details, Signature, Session Summary, and Company Header.
   • To select fields included in each preset section, except for “Session Summary” and “Company Header”, click Configure Fields.
   • In the “Configure fields” pop-up, click the checkboxes for fields to include in the preset section
     
   • Click Apply
   • In the “Signature” section, 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.
   • Select the Session Summary section and add an optional description.
6. Add Custom sections. 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.
7. After adding a section, users can edit the title and questions
   
   • Click the “up and down” arrows to reorder questions
8. 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.
   
   
   • Click the Page number location drop-down to select the orientation of the page number
   • Under “Add client identifying information,” click the Client full name, Client date of birth, or Client ID checkboxes, if needed
   • Click the Require change reason toggle under “Options” to require users to enter a short description when editing session notes
     
     
     • Please note, up to 300 characters can be entered for the description.
9. Click Save Template

To edit a Session Note Template:

1. Navigate to the Clinical module 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 Clinical module 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

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, click the “Create session note…” drop-down and enter a session note name to select.
   
   • Please note, the icons on the right-hand side of the session note will vary based on the user permissions enabled.
   • For users with the (Session Notes > Edit) permission, click the pencil icon to edit the attached session note. 
   • 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.
     
     
   • For users with the (Session Notes > Delete) permission, click the trash can icon to remove the session note from the timesheet.
   • 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.