Support Center

Chart Session Notes

Last Updated: Jun 08, 2015 02:22PM EST

Charting is an essential task in Even if you elect to maintain patient records elsewhere, you will still need to visit the charting screen to log patient payments and initiate billing. The easiest way to chart is to click the "chart" button that appears beside a patient's name on the daily schedule. Choose a CPT code from the list, enter the amount actually collected from the patient that day, and select the form of payment. By selecting the CPT code you will automatically fill in your usual fee for that service, but you can edit this number if you are giving a discount. You can select a Place of Service and fill in Units and CPT modifiers, but none of these is necessary in most small private practice settings.

If you are going to maintain patient records within the system (recommended), you will also need to enter session notes. You can choose (through "Preferences") which style of notes to use as a default. I recommend the "HIPAA-style" notes: these ensure that your notes contain the minimum amount of information suggested by HIPAA documents that constitute a chart note. On the top right of the screen, you'll choose several items from pull-down lists; you entries here will be remembered for the next time you chart. You can also choose to chart in the SOAP format, a quite comprehensive style of charting. A video explains it all; just click on the film symbol in the upper left corner of the charting screen to view it.

If insurance is involved, you must supply a diagnosis for the patient. You can enter up to twelve diagnoses by separating the diagnoses with commas, e.g. "300.00,296.34,301.83". V-codes are permitted, but be aware that you GREATLY reduce the chances for insurance reimbursement by including a V-code diagnosis. You can also enter an ICD mental health diagnosis. The system will alert you if it doesn't recognize a diagnosis code, and list the diagnoses in descriptive form if you like. (To do this, display the patient information and "hover" the cursor over the diagnosis code.)

If you don't remember the DSM code, you can have the software look it up for you. Just enter a phrase from the diagnosis and the software will list all diagnoses that contain that phrase. For example, if you enter "adjustment" in the diagnosis box, the software will list all of the adjustment disorders for you in a pick list.

If you elect to use HIPAA-style notes, you'll notice that there are two separate blanks for entering Medical Record Notes and Private Process notes. Private process notes (called "Psychotherapy Notes" in HIPAA) are very rarely released to others: they are subject to an extra layer of protection from disclosure under HIPAA. These may be the private musings of a therapist ("Why is he so hostile at the end of the hour?"), notes about fantasies, speculations, or jogs to memory ("Find out more about her relationship with her sister"). They are not considered to be a part of the medical record, if it is released. Therapists write these notes as reminders for themselves, not to convey information to others.

Medical record notes, also called "Progress Notes," contain information that would be useful to others involved in the patient's care, e.g. if the patient moves and must go to a new therapist. They may also contain information that justifies treatment or reimbursement. If a managed care reviewer calls about a patient, you would refer to progress notes, not process notes.

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