Permissions: Therapist can create Notes for their assigned Cases, Administrators or higher can create Notes for all Cases.
There are several way to access and add a Progress Note for a Client. This is the WebABA recommended workflow as it will link your Progress Note to a Client Appointment.
NOTE: If you are subscribed to e-prescribe, the client's active medications entered in e-prescribe will pull into a new progress note or new note that has been copied over from a previous session. Any changes made to client medications will not be reflected on existing progress notes, regardless if the note is signed or unsigned. If you see a wrong medication in an existing progress note, you will need to update the medication(s) in e-prescribe and create a new progress note to reflect the changes.
If a progress note has been signed or approved, you may need to refer to the printed document to view active medications.
Add a Progress Note
- Be sure an Appointment has been created for this Client.
- On the Schedule, navigate to appropriate Client Appointment.
- Click Add Progress Note button.
- If there are no cases for this Client, a new Case will be created.
- If a Case has been created for this Client that you are not assigned to, a new one will be created.
- If there are multiple Cases you are assigned to, you will need to select appropriate Case.
Complete a Progress Note
Once the Note has been added, add the appropriate information to complete and Save the Note.
- The Appointment and Place of Service will auto-populate upon creation.
NOTE: If you have proper permissions you can change the Place of Service on the Note.
- The Duration In Minutes field autofills with the Appointment length. If it was shorter or longer, edit that here.
- The Provider(s) on the Appointment auto-fill. You can add/remove any Staff Member who is assigned to the Case or already on the Appointment.
- Enter Mental Status and Risk Assessment. Type in the field and select from list or enter in a new phrase.
- The Diagnostic Impressions from the Behavioral Assessment tab and a History of Treatment Goals display. Click the Treatment Plan tab or the Initial Assessment & Diagnostic Codes tab to edit.
- As you fill in the Note, your draft auto-saves and will display a message in the top right corner.
NOTE: If you leave the page without pressing the green Save button, you can still retrieve the Note by clicking View Draft Copies of This Note. Loaded drafts disappear after the Note is saved.
- When you have completed the note click the green Save icon.
NOTE: There is no spell-check capability for Notes added at this time.