THERAPY NOTES
In this policy section you will find step-by-step procedures for all staff members who utilize TherapyNotes as part of our responsibilities within the practice. It encompasses the scheduling, onboarding and terminating aspects of TherapyNotes usage, including but not limited to: client record management, scheduling and appointment management, billing and payment processing, & communication and messaging. Documentation is a critical aspect of all client work at Droste.
Step-by-step Guide on How to Use TherapyNotes Effectively
1. Logging In:
Open your web browser and navigate to the TherapyNotes login page.
Enter your username and password provided by the Executive Director or designated personnel.
Click on the "Log In" button to access your TherapyNotes account.
2. Dashboard Overview:
Upon logging in, you'll be directed to the TherapyNotes dashboard.
The dashboard provides an overview of your upcoming appointments, tasks, and recent activity.
Familiarize yourself with the navigation menu on the left, which contains various modules such as Calendar, Clients, Notes, Billing, and more.
3. Scheduling Appointments:
Click on the "Calendar" module to schedule appointments.
Select a date and time for the appointment by clicking on the corresponding time slot.
Enter the client's name (using their initials) and other relevant details.
Save the appointment to confirm.
4. Managing Client Records:
Navigate to the "Clients" module to manage client records.
The Executive Director will add New Client (during the Intake).
Access existing client records by searching for their name or client ID.
Update client information, upload documents, and add notes as needed.
5. Taking Session Notes:
From the client's record, click on the "Notes" tab to create session notes.
Select the appropriate note type (e.g., Progress Note, Psychotherapy Note).
Document the session details, interventions, client responses, and any other relevant information.
Save the note to the client's record.
6. Communication:
Utilize the TherapyNotes messaging feature to communicate securely with clients and colleagues.
Access the messaging module from the navigation menu.
Compose a new message, select the recipient, and enter the message content.
Send the message and monitor responses within the TherapyNotes platform.
7. Reminders and Tasks:
Stay organized by setting reminders and tasks within TherapyNotes.
Access the "Tasks" module from the navigation menu.
Create new tasks, set due dates, and assign priorities.
Mark tasks as complete once they are finished.
Help and Support: - If you encounter any issues or have questions about using TherapyNotes, access the Help Center for resources and support. - Utilize the built-in help documentation, video tutorials, and FAQs to troubleshoot common issues. - Contact TherapyNotes support for assistance with technical or account-related inquiries.
New Clients in TherapyNotes
*Note: If you are working with an adolescent or a child with a cell # and/or email address, their number will be listed in a contact bar under information. However, the Parent’s email is used in the onboarding email inviting them to TherapyNotes, etc. Be mindful of whose address you are using when reaching out.
Opening a Client
First session is always selected to be an ‘Intake session’ in TherapyNotes — not 'therapy session’. This is because we want the system to prompt you to do a Treatment Plan and an Intake Note (this is an important funnel to subsequent progress notes). All subsequent sessions are ‘therapy session’(s). Service Codes for sessions correspond to Service Types of sessions.
For a clear understanding of the Notes you should be making with each client, be sure to read the Types of Notes course (next up).
Here is a Step-By-Step walk through for documentation.
Note: Do not check the box for ‘Sign this Form’ at the bottom of the Note until you have finished all editing to the note. To save the draft, just leave the ‘Sign this Form’ box unchecked and click Save Draft.
Initial Documents
Our Executive Director sends the applicable initial documents through the TherapyNotes portal when the matching email goes out. If, for any reason, you do not see those documents, please alert the Executive Director asap. Some documents, like the Welcome Packet, require an electronic signature, while others (like the payment authorization CC form; Emergency Contact info) requires information to be entered manually in the portal.
Any assessments sent through TherapyNotes will integrate into the portal automatically once completed. However, other assessments will be conducted outside TherapyNotes. (*Note: We are currently working on an Assessments Guide which will include outcome measures which will integrate into TherapyNotes and other outcome measures which will not. This is meant to give Therapists the option to conduct assessments in session or ask for assessments to be done on the client’s outside time.)
New Clients
All new clients should have completed and uploaded:
Client Contact Form: optional form if they want to provide emergency contacts
COVID Tx Disclosure Form: for clients who started between 3/2020 and 8/2023 this form was a requirement. As of Aug 2023, public health regulations shifted this requirement to be a health and safety notification of disclosure. This form is now a disclosure of risks for in person sessions. See Welcome Packet HERE.
Notice of Privacy Practices: outlines privacy practices of DMHS
Fee Acknowledgement: required for any client self-paying (not required of grant clients)
Payment Authorization: required for any client self-paying, even if they are intending to pay by zelle, check, or cash (not required of grant clients)
PCL-5: required at intake and every 6 months thereafter
PHQ-9: required at intake and every 6 months thereafter
If a client is struggling to complete the forms or hasn’t completed them electronically, assist the client in the first session and upload the forms yourself to TherapyNotes.
Here are a few items to keep in mind as a checklist:
After the first session, a Treatment Plan and an Intake Note must be completed for each client.
Every session thereafter should have a Progress Note completed.
Any contact with a client or collateral should be documented in a Contact Note.
Any assessments sent through TherapyNotes will integrate into the portal automatically once completed. However, other assessments will be conducted outside TherapyNotes. (*Note: We are currently working on an Assessments Guide which will include outcome measures which will integrate into TherapyNotes and other outcome measures which will not. This is meant to give Therapists the option to conduct assessments in session or ask for assessments to be done on the client’s outside time.)
HERE is a Youtube video step-by-step for Getting Started in TherapyNotes.
Required Ongoing Documentation
Treatment Plan’s must be in place before a progress note can be written.
Scheduling Clients in TherapyNotes
To schedule a client in TherapyNotes, follow these steps:
Log in to TherapyNotes: Visit the TherapyNotes website and log in using your credentials.
Navigate to the Calendar: Once logged in, navigate to the Calendar section. This is typically found in the main navigation menu.
Click on the Date: Choose the date on which you want to schedule the client by clicking on the appropriate date in the calendar.
Create a New Appointment: Click on an available time slot on the selected date to create a new appointment.
Select Client: A window will pop up where you can select the client for whom you want to schedule the appointment. Begin typing the client's name in the search box, and TherapyNotes will display matching results. Select the correct client from the list.
Specify Appointment Details: Once you've selected the client, you can specify the details of the appointment, including the date, time, duration, and location (if applicable).
Add Additional Information: You can add additional information to the appointment, such as session type, billing details, and any notes relevant to the appointment.
Save the Appointment: After filling out all necessary information, click the "Save" button to schedule the appointment.
Confirmation: TherapyNotes will typically provide a confirmation message once the appointment is successfully scheduled. You may also receive email notifications depending on your notification settings.
Review and Manage Appointments: You can review and manage scheduled appointments in the Calendar section of TherapyNotes. From there, you can make changes, reschedule, or cancel appointments as needed.
Therapy Notes Videos
Further Info & Help w TherapyNotes
→ ‘Profile’ → ‘Help’
Here you will find articles with step-by-steps of how to do any number of things from syncing your TherapyNotes calendar, to preference settings, to HIPAA-compliant video sessions to new client set-up & Notes.
YouTube Therapy Notes Videos:
Here you will find a number of helpful step-by-steps on YouTube to further help you acclimate and orient yourself in TherapyNotes.
Please find links to more Youtube TherapyNotes Training videos below:
Note Template Updates in TherapyNotes
Terminating of Clients
Termination Note
If you terminate with a client (for any reason), you must complete a Termination Note.
If a client doesn’t respond to outreach and an initial session hasn’t been completed, document via a contact note that you notified the client of case closure and how to reach out again if they are interested in a contact note. No termination note is necessary as clinical work was not initiated.