You can now document clinical encounters that happen outside of a scheduled session in the Chart notes section of a client’s Clinical tab in the provider portal. These notes become part of the client’s record and help keep everything in one place.
Chart notes are clinical notes that cover interactions outside of a standard session. They include:
- Telephone encounters
- No-show documentation
- Discharge summaries
Adding a chart note
These notes live in the client’s Clinical tab, under the Chart notes section. To add a note:
- Visit the Clients tab in the provider portal
- Click into the client’s profile, and open the Clinical tab
- Scroll down to the Chart notes section
- Click Add
Note types available
When adding a note, you’ll choose one of four options:
- Telephone encounter – free text
- No-show note – free text
- Other – free text
- Discharge summary
- For most providers: free text or optional template
- For M&M providers: required template
Saving and editing chart notes
You can choose to save a draft if you’re not ready to sign the note right away.
To return and edit the draft, click the menu on the right side of the note. Once the note is signed, you can view or download the note using the menu. You can also choose to add an addendum to the previously saved note.
Note: Downloading isn’t available for templated discharge summaries for M&M clients.
Writing a discharge summary when archiving a client
When you archive a client, you'll be prompted to select a reason. In most cases, you'll also see a pop-up encouraging you to write a discharge summary.
Writing a discharge summary isn't required unless you're an M&M provider, but we highly recommend it to close the loop on care.
You won’t be prompted if you select one of the following reasons:
- Decided prospective client was not a good fit
- Client paused care for personal reasons
- Client never attended a session
FAQs
No. Chart Notes are intended for clinical documentation only. They aren’t tied to billable or scheduled appointments.