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.

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

⚠️ Note: Change the Date up top, if it's not for today.

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

⚠️ Note: We support the ability to change the CPT code cost directly from charting, highlighted below! You can manually change the amount if different from the default CPT code cost you normally charge.

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:

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!

⚠️ Note: Want to use a template in addition to using the standard HIPAA chart note template? You can! Read the above link, and learn how to create a HIPAA Note Template, highlighted below:

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.

⚠️ Note: more information about that here: automatic payments when charting

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

⚠️ Note: Make a mistake or need to add something additionally to the chart note after permanently locking it? Please check out these other options after locking a chart note: