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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: Top to bottom
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:
- Click the button:
Charting: From the Schedule View
- Click Schedule (left menu)
- Click on the appointment you wish to chart on:
- Select the button
- Then click here for the next steps
- Charting from the Today view instead? Read on!
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 you typed out a HIPAA or SOAP note style template like above, the fields are remembered, leaving you to continue where you left off.
Here we will break down each charting templates, use the links below to jump to a specific one:
HIPAA
- With this template, we "remember" or pull forward everything in the top sections: from Symptoms down to Diagnosis Codes, shown below:
- We don't pull forward the last Notes section by default so it will be blank, but below you will have the option to copy the previous appointment note by clicking the button below that section,
Simple (Narrative Note)
- You can edit the Diagnosis Codes
- It will start with a blank Notes section
- We auto-populate the chart with the client name, appointment date & time, CPT code, and diagnosis automatically above
- Similar to the HIPAA template it also has the option to copy the previous note under the Notes section
SOAP Notes
- For SOAP (Assessment) notes, all values are pulled forward from the previous SOAP note.
- 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.
Chart Note Templates
- When using chart note templates we load whichever template you select.
- Above the Notes you can update the Diagnosis Codes
Example:
There are two different approaches to using a "last chart entry" on a charting template. Below we will break down each option, recommended in order:
- Clicking (right menu buttons on appointment popup) allows you 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 to a Simple template with the entire previous chart note.
- Variables ({AUTOTEXT}) are hardcoded here. For example, for the date field it fills in the date from the previous appointment vs. the new appointment, since it copied the entire previous chart note exactly as-is.
- Some of this you will want to remove unless needed for context, since it will already be populated in the note header highlighted below:
Picking from the HIPAA Note Template option leads to the selected note template loading below in the notes section of the HIPAA template:
Treatment Plan
Want to include a treatment plan? Toggle this to Yes to expand the treatment plan section
Enter or edit your client's treatment plan, and optionally set the next treatment plan due date.
Note: Setting a due date shows up on your dashboard! Click here for more info
Private Notes
Any notes entered here will only be visible to the provider (or records custodian) and will not be included in the clients chart when printed.
🎉 Congratulations, you've finished your chart note!
At the bottom right corner, click .
This brings you to the chart review screen. Review your chart note for any issues or errors as well as any automatic charges and scroll down.
After you've reviewed the note and it looks good as well as any automatic payments, scroll to the bottom and find the three buttons:
- Click to electronically sign & permanently lock the chart note
- Click if you wish to return to this chart note later to edit and lock, but not yet
- Click to be brought back to the chart note draft