Client Electronic Health Record (EHR) - Overview

TheraNest is designed to help you organize, and keep secure, the client electronic health record (EHR). Using Client Details page, client, case and progress note forms, and by uploading completed General Documents. The complete EHR can be accessed all from one place depending on specific permissions granted within the system.

This article provides an overview of the Client page and information that can be gathered as part of the EHR. It then covers additional information that can be gathered through client, case and progress note forms; and by uploading completed forms into General Documents.

Jump to Section [Client Details and Dynamic Client Forms] [Cases and Dynamic Case Forms] [Progress Notes and Dynamic Progress Note Forms] [Staff Permissions & Client Access] [FAQs]

Client Details and Dynamic Client Forms

  Permissions: All Staff can add Clients in TheraNest and access all basic Client information unless "Can view only assigned client information" is checked in Therapist permissions (see below).

NOTE: Client Details should not contain any clinical information.

 

Client Details

By accessing the Client you see the Client Record or Client Details (in TheraNest). From there you can see and enter information into the EHR based on permission level. Client Details contains administrative information including:

• Client Name
• Contacts
• Address
• Emergency Contact
• Client Notes
• Income and Payment Amounts
• Health Insurance Information
• Demographic Information
• Household (family) Information

The Client page also has tabs and links to other information including Additional Details, Insurance, Assigned Staff, Family, Contact Network, Reminders and Reports. 

Dynamic Client Form and General Documents

Dynamic Client Forms can also be created to gather specific information about clients by staff or by the client through the client portal as an Intake Form. Completed intake forms will be displayed in the General Documents tab as a pdf file. 

Cases and Dynamic Case Forms

  Permissions: Access is determined by Client assignment and User Permissions (see below). 

Cases

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.

Dynamic Case Forms and Clinical Documents

Dynamic Case Forms can be created and used to capture specific Case information and may include dynamic elements pulled from TheraNest. Dynamic elements are:

• Client Full Name
• Client Email
• Client Mobile Phone Number
• Client Id Number
• Client Date of Birth
• Client Address
• Client Diagnosis

*Dynamic Case Forms may be created and shared as either a shared form or as an intake form. Please note:

Shared Form

1. When the Dynamic Case Form DOES NOT include Client Diagnosis it can be shared through either General Documents in Client Details OR Clinical Documents in Notes.
2. When a Dynamic Case Form DOES include Client Diagnosis it can ONLY be shared through Clinical Documents in Notes.

Intake Form

1. When a Dynamic Case form is created or shared and includes Client Diagnosis it can be included as part of the intake package. If the client diagnosis has been made, it WILL NOT display the diagnosis when being completed or in the printed version. The Diagnosis ONLY displays when shared via Clinical Documents in Notes. This is to protect client PHI.

Progress Notes and Dynamic Progress Note Forms

  Permissions: Administrators and assigned Therapists can view and add Progress Notes to a Case. 

Progress Notes are designed to capture session info as well as treatment updates for each session. A Standard Note and SOAP Note are included in the system.

Custom Dynamic Progress Note forms can be created for specific types of appointments or uses and be set as a default for the system or for specific Therapists.

When Wiley Practice Planners are used, information from the planner will be automatically pulled into a Dynamic Progress Note form.

General Documents

General Documents is a tab on the Client Details page where completed intake forms are stored and provides a place to upload scanned copies of paper forms completed by the client.

General Documents include shared forms which are Intake Forms completed by the client in the Client Portal. The Shared Forms section allows you to resend intake forms or send new intake forms for the client to complete electronically in the Client Portal.

Clinical Documents

Clinical Documents is a tab on the Client Details > Notes where Case Forms can be distributed via the client portal and provides a place to upload scanned copies of paper forms completed by the client. Case forms completed by the client in the portal are stored here. Clinical Documents, being part of the client case, is only accessible to providers assigned to the case. This allows you to include a client diagnosis on the case form keeping the PHI secure. If a case form that includes a diagnosis code is mistakenly included in an intake packet, the diagnosis is not displayed.

General Documents include shared forms which are Intake Forms completed by the client in the Client Portal. The Shared Forms section allows you to resend case forms or send new case forms for the client to complete electronically in the Client Portal. Case forms that include a diagnosis code can only be shared from this page.

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 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

1. In order to create a Client Case and/or view a Client's Clinical information, Staff Member must be assigned to the Client.
2. 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.
3. If someone else creates 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 Progress Note form?
  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 form?
  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 form?
  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.