TheraNest is designed to help you organize and keep secure the client electronic health record (EHR). Having followed the process outlined you will have looked at:
- Client and client details in Build Your Client EHR
- Intake Forms in Welcome Clients to Your Practice
- Managing the workflow for the EHR in Leverage your Agenda
Now we look at Client Cases and Notes, how they are created and managed to complete the EHR up to the invoicing and billing processes.
Customized forms can be created using the Dynamic Forms feature. Dynamic forms are broken into four distinct types:
- Organization
- Client
- Case
- Progress Note
This article looks at these dynamic forms and how they are created and used within the system to complete the client EHR.
- Organization, Client and Case forms are treated as one group as they share similar characteristics and form elements
- Progress Note forms and their use are dealt with separately as they are more secure and contain client PHI in their dynamic elements.
Organization, Client and Case Forms and Notes
Notes are used to document and save information about the client and are secured in the system depending on the information. Notes include:
- Client: Located on the Client Details and displayed on the agenda. Anyone with access to the client’s details and agenda can view.
High visibility, low security. - Contact: Located on Contact Log tab on the Client Notes page. Anyone with access to Case can access.
Medium Visibility, medium security. - Case: Located on Clinical Documents tab on the Client Notes page. Therapists assigned to case can access.
Low Visibility, high security. - Progress: Located on Progress Notes tab on the Client Notes page. Therapists assigned to client and supervisors can access.
Low Visibility, high security.
Forms are used to both provide and gather client information. Each type of form can be customized and accessed based on type:
- Organization
- Client
- Case
- Progress
- Intake
The video below is from our webinar Standard Notes and Dynamic Progress Note Forms Basics and the written information can be downloaded and printed from this quick reference Feature Guide.
Dynamic Forms
Forms are used to both provide and gather client information. Each type of form can be customized and accessed based on type:
- Organization Form - Dynamic Forms Page (not an intake form)
- Client Form – tab on Client Details
- Case Form– tab on Client Notes page
- Progress Note Form - selected when creating a Progress Note
Progress Notes
Best Practice Workflow
- Create a progress note from an appointment on the agenda and leave unsigned (can go back and edit until it is signed)
- Create a new progress note from available forms, which gives the option to pull previous session, diagnosis and treatment plan history
- Note is signed by therapist when finalized
- Further changes are not allowed to signed notes, only addendums, which are signed
The video below is from our webinar Dynamic Progress Note Forms and can be downloaded and printed from this quick reference Feature Guide.
Dynamic Progress Note Form
Dynamic Progress Note Forms automatically include Header Information which is basic information about the client pulled from Client Details. Standard and Dynamic form elements are used to customize forms.
Standard Form Elements:
- Static Text
- Open Text Fields
- Lists and checkboxes
Dynamic Form Elements:
- Pulled from client details and case information
- Dependencies on Diagnosis, treatment plan and treatment goals that must completed prior to completing forms which include those elements
- include Mental Status and Risk Assessment Options