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Edit or Delete Psychotherapy Note

Updated: 11/10/2023|Views: 662

Psychotherapy notes, also called process notes, are personal notes of a mental health care provider that are separate from the patient’s medical record and are not accessible by the patient, other providers, or staff members in the practice.

When psychotherapy notes are enabled, providers can create psychotherapy notes and continue editing to document their personal observations and insights related to the therapeutic session. The option to edit a psychotherapy note is available from the patient's Notes page or through a clinical note. If the psychotherapy note is no longer necessary in the patient's chart, the psychotherapy note can be permanently deleted.

Psychotherapy notes cannot be disclosed without the express authorization of the patient, except in limited circumstances required by law. This feature should not be used for any purpose other than the documentation or analysis of the contents of a counseling session by a mental health professional.

Access Patient Notes

  1. Enter the first 2–3 letters of the patient's name or date of birth (mm/dd/yyyy) in the top navigation bar search box.
  2. Click to select the patient from the auto-populated results. The patient's Facesheet page opens.
  3. Click Notes. The Notes page opens.
Clinical_Notes_Access.png

Edit Psychotherapy Note

The option to edit a psychotherapy note is available from the patient's Notes page or through a clinical note. The provider can continue to document their personal notes in the patient's psychotherapy note.

The psychotherapy note is automatically saved approximately every 30 seconds or when a change is made to the note to increase productivity and avoid data loss.

Edit from Notes Page

  1. Click Open. The Psychotherapy Notes page opens.
Clinical_PsychotherapyNotes_Open.png
  1. Enter or edit content in the text editor and format as desired.
    Note: Clicking Back to return to the notes page may not save all new edits. To save all changes, use Save & Close.
    icon_tip.png Tip: Enter the current date with new or edited content to track historical changes.
    • Available formatting options: Bold, Italicize, Underline, Bullet, and Numeric
  2. Click Save & Close when finished.
    • To permanently remove the psychotherapy note, click Delete. Then, click Yes, Delete to confirm that all documentation will be deleted and will not be recoverable. The note is removed and the option to create a new psychotherapy note displays on the Notes page.
Clinical_PsychotherapyNotes_EditNotes.png

Edit from Clinical Note

Providers can enter their clinical documentation and edit their personal notes at the same time.

The psychotherapy note is automatically saved approximately every 30 seconds or when a change is made to the note to increase productivity and avoid data loss.

  1. Create a clinical note or open an existing clinical note.
  2. Click Show Psychotherapy Note. The Psychotherapy Notes panel opens to the right side of the note.
Clinical_Psychotherapy_Show.png
  1. Review, enter, or edit content in the text editor and format as desired.
    icon_tip.png Tip: Enter the current date with new content to track historical changes.
    • Available formatting options: Bold, Italicize, Underline, Bullet, and Numeric
  2. Click Hide to close the Psychotherapy Notes panel.
Clinical_Psychotherapy_Hide.png

Delete Psychotherapy Note

The psychotherapy note can be deleted if the psychotherapy note is no longer necessary in the patient's chart. Removing the note will permanently delete all documentation and is not recoverable.

  1. Click Delete. The Are you sure you want to delete? pop-up window opens.
  2. Click Yes, Delete to confirm. The note is removed and the option to create a new psychotherapy note displays on the Notes page.
Clinical_PsychotherapyNotes_Delete.png
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