Creating a Session Note
You can write notes in a way that works for you and your business. Note templates allow you to focus on writing your note without worrying about formatting or forgetting information that you need to record.
In this article:
Creating a Note
You should create a note template(s) prior to creating a note.
- To create a note for a client go to their record and click Records > Notes.
- To create a note simply click + New Note.
- Simply select a template to begin writing your note.
- Fill out your note as required. Once complete simply click either: Save as Draft (if you plan on editing/coming back to the note to make changes) or Save as Locked (to finalise the note, once locked it cannot be edited).
Frequently Asked Questions
How can I see who authored a note?
The username of the author is displayed toward the bottom right of the session note.
Can I unlock a locked note?
No. Once a note has been locked it can no longer be unlocked, edited or deleted and will become a part of that client's permanent record. If you plan on revisiting a note or making changes to it at a later date please save as draft. (This is to ensure compliance with relevant Health Records laws and regulations.)
How do I manage my note templates?
Note templates are managed via Setup > Note Templates. You can learn about managing and creating note templates in this article.
How do I print all notes for a client at once (ie. for a subpoena)?
You can simply go to the client's record, navigate to Records > New Notes and click Print Notes. Alternatively, if you would like the entire client record for the client in a machine-readable format you can go to Tools > Data Export and use the single client export function.