TheraPlatform has default notes that can be used instantly and a library of note templates. You can modify our templates and build any note template from scratch to meet your practice's needs.
You can build your own Chart note templates, Assessment and treatment plan templates, Progress notes (clinician/therapy notes) templates and discharge note templates.
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.
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.
You can also modify our built-in note templates. To learn how to edit our built-in templates, refer to this article.
Important: 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 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).
Step 1: Click on Settings.
Step 2: Click on Notes.
Step 3: Click on the note type you would like to build a Template of. Chart Notes, Assessment and Treatment Plan, Progress Notes, or Discharge Notes.
Step 4: Click on Add form.
Step 5: A pop-up box with a toolbar will open.
Step 6: Enter the name of your new note template in the Form Title box.
Step 7: If you want this new note template to be available for you (administrator) and your therapists, make sure that the switch Enabled is on.
Step 8: Mark the other options to meet your needs such as:
- mark the note template as default
- hide your logo so your logo does not show on the print out version of the note
- hide score : when you add objectives under goals under treatment plan, they will carry over to your progress notes TheraPlatform allows you to score them. However if you don't want to display any scoring, you can mark the note template with Hide Score
- 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 blue, one will be able to put the expiration date on the treatment plan.
Step 9: Using our toolbar, add fields with your questions or statements.
To add a field to your form, click on one of the buttons on the toolbar.
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 to ask your questions (or state) and add multiple options and your client will be able to select MORE than one of the options. To add multiple options to your statement or question, click on edit.
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: To preview your new note template, click on Preview before you close the builder.
Step 10: Click on Save Changes.
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.
Customize Your Template Footers
To learn how to add a footer to your templates, visit: How to Add Footer to Note Templates, Intake and Consent Forms for a step-by-step guide that walks you through adding patient or physician details to your notes and forms quickly and easily.
Related Articles
- How to Use Form and Note Editor
- How to Add Footer to Note Templates, Intake and Consent Forms
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