Start Charting
Chart notes are a key and essential part of documenting what happened in session and your client's progress.
Are there uncharted notes that exist for a client? Or perhaps a CPT code needs updating or adding?
TherapyAppointment offers several access points to the session documentation pages.
In this Article
- Charting: From the Dashboard View
- Charting: From the Schedule View
- Charting: From the Today View
- Charting (in general)
Charting: From the Dashboard View
- From the Dashboard (top left menu)
- Find the top left section Today's Appointments
- Click on the client's name:
- Select the button:
Charting: From the Schedule View
- Click Schedule (left menu)
- Click on the appointment you wish to chart on:
- Select the button
Charting: From the Today View
- Click Today (left menu)
- Click on the appointment you wish to chart on, revealing a dropdown for that appointment
- Then select the button
Charting
When charting, you'll want to complete this process from top to bottom to avoid mistakes or missing information.
First, you'll want to select your chart entry style: either using one of our pre-built templates ( HIPAA and SOAP Notes), or your own chart note template:
First you can define the specifics, including:
- Chart Entry Style (SOAP Note, HIPAA, Simple, or Chart Templates, explained below)
- CPT Codes (price & quantity)
- Service Modifiers
- POS Code
- Appointment start & end times
Beneath that comes the actual chart note. Here's an example of our HIPAA style template:
The Notes section is where your remaining chart notes for the session go. We support rich text formatting, like section headers and different size font, bold, italics, and underline alongside bullet point, numbered lists, and indentations.
Charting Behavior
When charting on a client, the system for the most part "remembers" the last entered chart note. So, if for example you typed out a HIPAA style template like above, the top fields are remembered, leaving you to continue where you left off.
Want to automatically load the last appointment's " notes" section too? Use the button below the Notes section to do that!
HIPAA & Simple
This applies to the following chart note templates:
- HIPAA (Progress Note)
- With this template, we pull forward everything in the top sections: from Symptoms down to Diagnosis Codes, shown below:
- Simple (Narrative Note)
- Will start with a blank Notes section
- Auto-populates Client name, Appointment Time & Date, CPT Code, and Diagnosis automatically
- Similar to HIPAA template, it also has the option to copy the previous note under the Notes section, shown below:
- Will start with a blank Notes section
SOAP Notes
- SOAP (Assessment) Notes are automatically pulled forward from the last previously charted SOAP note in the system.
- Once a SOAP Note is charted on, even if you've charted with another chart type since, changing the chart entry style back to SOAP Note will pull up the last previously entered SOAP Note.
Custom Chart Templates
- Custom chart templates will load just the chart note template at it's core
- It will not load the last entered chart entry.
- Looking for that? Instead consider either of the following:
- Clicking (right menu buttons on appointment popup) to review and copy some of the previous entry. Then go back to the appointment, start charting which brings up the previous custom chart template used. Paste whatever you need while charting and continue as you normally would. This would be ideal if you would like to continue to use the {AUTOTEXT} features.
- While charting, select previous chart note for Chart Entry Style at the top. This will load the previous entry. We essentially convert this chart template to a Simple template with the entire previous chart note entry. So that does mean that the {AUTOTEXT} will not auto populate. Some of this you will want to remove, since it will already be populated in the note header highlighted below:
Chart Templates
When using chart note templates we load whichever template you select. From here: further fill in and edit as needed and you're on your way!
Which then leads to the selected note template loading below:
Treatment Plan
You can include a treatment plan as a part of the chart note by toggling it from No to Yes.
Enter or edit your client's treatment plan, and optionally set the next treatment plan due date (shown on your dashboard automatically when within 2 weeks!)
From there, click at the bottom, review your chart note for any issues or errors as well as any automatic charges.
- Clicking to permanently lock the chart note
- Click if you wish to return to this chart note to edit and lock later, but not yet
- Click to be brought back to the chart note draft