Each Organization has their own vocabulary and yet, so does TheraNest. In TheraNest we use Client, Case and Note in place of terms like chart, patient, file, etc. This article will walk you through the difference between a Client, a Case, and a Note as well as what information is stored in them and who has access.
Permissions: All Staff can add Clients in TheraNest and access basic Client information unless "Can view only assigned client information" is check in Therapist permissions (see below).
Client refers to the Client Record or Client Details. The Client Details section of the Client record contains administrative documentation such as Demographics, Insurance, and Billing.
NOTE: Client Details does not contain any clinical information.
Permissions: Access is determined by Client assignment and User Permissions (see below).
A Case is a collection (like a file folder) of Notes and clinical information for a Client. Cases provide a higher level of privacy for Client information such as Initial Assessments, Diagnostic Codes, Progress Notes, Treatment Plans, etc., keeping this information separate from a Client's basic record.
Sometimes Client can have multiple cases, for example if they have individual appointments and are apart of a Group, there would be a Case for their individual session Notes and another Case for their group session Notes.
Permissions: Administrators and assigned Therapists can view and add Progress Notes to the Case.
Progress Notes are designed to capture session info as well as treatment updates for each session. By default, the Standard Note, or a Progress Note is enabled. As an Administrator you can enable non-default notes such as SOAP Notes.
Please keep in mind there is no universal mental health note format, or more specifically, no format that is universally accepted by all insurers. We have attempted to create a Note format which is acceptable to the majority of providers and to the insurers they work with.
Additionally, Wiley Practice Planners, which we integrate with, require mapping certain kinds of data to specific fields, so these fields need to match the content of the data provided in the Wiley Planners. If you choose to use Custom Forms they cannot replace the Progress Notes within TheraNest.
Staff Permissions and Client Access
As stated above, Staff access to a Case is determined by Client assignment and their User Permissions. Because Cases have a higher level of privacy, Staff Members must be assigned to Clients AND also be assigned to the Case.
By default Staff Members can access Client Details unless, as a Therapist, you have selected that they can only view assigned clients permission.
If this permission is checked, the Staff Member won't see ANY Clients in TheraNest unless they are manually assigned to a Client. They could search a Client name and nothing would display if they aren't assigned to that Client.
If this permission were unchecked, the Staff Member could search for any Client and see they are a Client.
Related Article: Assign Staff Permission
- In order to create a Client Case and/or view a Client's Clinical information, Staff Member must be assigned to the Client.
- Once a Staff Member is assigned to a Client they can create a Case. If you create a Case, you will automatically be assigned to that Case. Being assigned to a Case means that you can input and view Clinical Information such as Progress Notes, Treatment Plans, etc.
- If someone else create's the Client's Case, you can be assigned to the Case by the Staff Member who created it or an Administrator.
Case & Notes FAQs
- Are Signatures required for my Notes? Can I require Signatures?
TheraNest does not require you to sign documents and there is not a way to make signatures required. You may implement your own business standard operating procedure that requires signatures. Also, some Payers you submit to may require you to sign your Notes or Treatment Plans.
- Can I import my own Note Template?
At this time existing Note Templates can’t be imported into TheraNest. However, you can create custom forms in TheraNest to create your own forms and collect any supplemental information our forms do not collect for you.
- Can I edit the Progress Note Template?
You can remove all fields or sections that are not applicable to you. This is an Organization wide setting and cannot be customized by Therapist.
- Can I add my own fields to the Progress Note template?
Not at this time! But please vote on that idea and leave any specific feedback/suggestions you want the product team to be aware of here.
- Are TheraNest Notes Medicare compliant?
Medicare compliancy is guided by state Medicare/Medicaid rules. There is no universal mental health note format, or more specifically, no format that is universally accepted by all insurers. We have attempted to create a note format which is acceptable to the majority of providers and to the insurers they work with.
If you need to comply with a particular policy based on your region and our progress note template does not meet your needs, you are welcome to design your own note using the custom form builder or reach out to our support team.