![]() SOAP stands for subjective, objective, assessment and (treatment) plan. I learnt this back in nursing school and it’s a great tool to use. A good format to try would be the SOAP format. Personally, I make sure to write any treatment I have provided in addition to my assessment and observations of the client in session. If you were ever subpoened in a court case, chances are your notes will be. ![]() It is up to you what to include in your notes. Writing session notes are essential because it is your professional and ethical duty to track the progress of your clients. I find these are the four that I use the most. These include documentation for client files such as a consent form for treatment, an intake form, session notes and payment receipts. You can select Add Attachment to upload and store a file in connection with the treatment summary.There are certain administrative requirements that are mandatory to operate your counselling private practice.When creating a treatment summary, the following fields must be completed: This note is flexible and can be used before, during or after a patient's course of treatment. ![]() You can select Add Attachment to upload and store a file in connection with the contact note.Ī Treatment Summary can be used to summarize a patient's treatment or planned treatment.Description: Option to include a description of the document(s) in the text box below.When creating a document, the following fields must be completed: Multiple files can be uploaded within one document. Therapists can use the document type to upload and store additional files such as administrative documents, patient assignments, medical records, and audio files. You can select Add Attachment to upload and store a file in connection with the supervision note.When creating a supervision note, the following fields must be completed: Supervision notes are notes used to document a therapist's interaction with a supervisor or supervisee regarding a patient. You can select Add Attachment to upload and store a file in connection with the c ontact note.You have the option of indicating who the contact was within the Contact field.Time: The current time is automatically selected, however you can adjust the time as necessary.Method: Identify whether the contact took place in person, by telephone, video, email, voicemail or fax.When creating a contact note, the following fields must be completed: Entries may include details on scheduling, follow-ups, and logistics. Therapists can use contact notes to reflect communication with their patients. This feature might be used to note medication changes, significant life events or other relevant items to contextualize a patient’s results. Event notes are visible on the note summary page andoverlayed on the progress graphs in a patient's results display.Ĭlick here for more information about creating and viewing event notes. Therapists can create event notes to record brief observations to be overlayed onto the patient's results display. You can select Add Attachment to upload and store a file in connection with the session note.Date: Today's date is automatically selected, however you can select a different date by clicking on the calendar.Method: Identify whether the session took place in person, by telephone, or video.Duration: Select from 15 minutes – 120 minutes.Session notes are notes taken by therapists to document or analyze the content of a conversation during a therapy session. When creating a session note, the following fields must be completed: There are six types of progress notes available on the platform.
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