Edit and Modify Existing Note Templates from Library

TheraPlatform (certain plans only) offers a built-in library of note templates. Our note templates can be modified to meet your needs.

In addition to our note templates, the administrator can create or build any note template from scratch to meet your practice's needs. 

If you have multidisciplinary practice or your providers have different professions, you can also assign note templates specific to the provider type. To learn how to assign these, review this article.

We offer: Chart note templates; Assessment and treatment plan templates; Progress notes (clinician/therapy notes) templates and discharge note templates.

TIP: Watch our built-in video tutorial (log in to your platform) under the orange button Watch tutorials, titled "How to set up note templates" (under Set-up section)

Assessment and treatment plan- allows you to document your evaluation findings, recommendation and plan with goals and enter diagnostic codes. The diagnostic code/s auto populate to your progress notes (aka therapy notes).

Progress notes (aka therapy notes) - These are your clinical/therapy notes to document what occurred during session, progress, etc. Under progress notes tab, you will find templates such as SOAP, DAP, BIRP, etc. Progress notes aka therapy notes are linked to a scheduled appointment, assessment and treatment plan, billing and claims. 

Chart notes are "free standing" on TheraPlatform. This means that you don't have to schedule to write a chart note and chart notes are not associated with assessment and treatment plan or billing. Chart notes can be used to document events that did not occur during your therapy meeting (e.g., phone call conversation, etc.). If you plan on submitting claims, creating superbills and billing you need to use progress note option.

Important: When you edit/modify our note templates or when you build your own note template (any one: chart, assessment and treatment plan, progress note, etc.), you don't need to add fields related to your client's demographic or your practices information as these automatically populate to print out version of notes from the client's chart and settings.

When you edit our note templates or when you build your own assessment and treatment plan, you don't have to add fields related to goals, objectives and interventions as we automatically have the green button Goals on the assessment and treatment plan where you enter the goals (as needed).

To edit our note templates, follow these steps:

Step 1: Click on Settings.

Step 2: Click on Notes.

Step 3: Click on the note type you would like to modify/edit ( Chart Notes, Assessment and Treatment Plan, Progress Notes, or Discharge Notes).

Step 4: Click on Browse Library. You can enter the name of your profession to find what you need quicker. For example, type "mental health",  "speech therapy", "occupational therapy", physical therapy", etc. 

Step 5: Click on the eye icon to review the note template.

Step 6: Click on Select next to the title of the note you wish to edit. This will move the template below to the white area, where you will be able to edit it.

Step 7: Click on the pencil icon to edit next to the template that moved to the white area.

Step 8: A pop-up box will open and you can start editing this note template. You can edit the title of our note template, remove fields, add new ones, etc. 

You can also modify the following on the note template:

• Mark the note template as the default. This is your default note template
• if you wish, you can hide your logo so your logo does not show on the printout version of the note
• hide score : When you add objectives under goals under treatment plan, they will carry over to your progress notes, and TheraPlatform allows you to score them. However if you don't want to display any scoring on the print out version, you can mark the note template with Hide Score and our system will not show it on the print our version of the note.
• require diagnostics so you and your therapists when documenting always enter diagnostic code (the system will not allow them to save the note without entering diagnostic code- great for reducing missing diagnostic codes for claims)

• require expiration: when marked in purple, one will be able to put the expiration date on the treatment plan.

  How to Add New Fields to a Template

  To add a field to your template, click on one of the buttons on the toolbar. You can either add them with a single click—placing them automatically at the bottom of your template—or drag and drop them exactly where you want. 

  Option 1: Add a Tool by Clicking the Tool. This is the fastest way to add a button, especially if placement at the bottom of the template works for your layout.

  

  Option 2: Drag and drop a Button Anywhere on the template. If you want more control over placement, drag-and-drop is the way to go.

  

 Text Box: This will allow you to write your question or statement and your client will be able to provide a short answer with a sentence or two. 

Numeric Options: This will allow you to insert numbers.

Options: This will allow you to ask your question (or state) and add multiple options but your client will be only able to select ONE of the options. To add multiple options to your statement or question, click on edit. 

Multiple options: This will allow you ask a question and add multiple options, allowing your client to select more than one. To add or edit multiple options, click Edit. For this field, you can also choose how the options are displayed by selecting a Vertical, Horizontal, or Column layout.

Paragraph: This will allow you to ask your question (or state) and your client will be able to provide a paragraph long answer.

Yes/No: This will allow you to ask your yes/no questions and your client will be able to either select yes or no.

Date: This will allow you to write your statement or question and calendar will be inserted to your new intake form. Your client will be able to mark the date on the calendar on your intake form.

Date and Time: This will allow you to write your statement or question and calendar with time will be inserted to your new intake form. Your client will be able to mark time and the date on the calendar on your intake form.

Header: This will allow you to insert header to your new intake form.

 Signature: This will add a signature field and one can draw signature in it.

Table: This will add a table and you can specify how many columns.

Step 9: Click on Preview.

Step 10: When you finish editing your new note template, please review the document again and make sure that the new note is marked as enabled. If your new note is not marked as Enabled, it will not be available for you and your therapists to use.

Step 11: Click on Save changes.

You can set up as many templates as you want and switch between templates when you document.

Customize Layout for Multiple Options

When using the multiple-option fields, you can control how choices are displayed on forms. You can choose to display options vertically, horizontally, or in columns, giving you more flexibility in how your forms are presented. Please note: this layout setting only applies to fields with multiple options 

Note:  Our system allows users to score goals that you enter when documenting assessment and treatment plan. You can score your goals with buttons: correct, incorrect and approximation and our system will score accuracy.  If you don't wish to see a scoring tool on your assessment and treatment plan, mark in blue "Hide score" (click on the green edit next to the name of the assessment and treatment plan and at the pop-up box, hide score). Hiding this scoring from the assessment and treatment plan, will also hide it from progress notes.

In addition, we show goals, objectives and interventions that you enter when documenting assessment and treatment plan on your progress notes (therapy notes). If you don't wish to see these on your therapy notes, make sure you mark the progress note template as "hide goals". 

To add footers to note templates follow these steps:

Step 1: Click on Settings < Notes< Settings

Step 2: Follow directions on the screen and enter footers in the fields needed.

Step 3: Click on Save changes.

Note:  After you sat up your note templates, you can also assign specific note templates to specific provider type. This will save your clinicians time as only assigned to them templates will pull vs all templated when documenting. To learn how to assign these, refer to this article.