Custom Notes: How to Setup a New Note Template
This section provides an overview for how to create a note template. This is the first step in creating customized note templates, or other related forms.
To set up a note template, go to Configure–>List Configuration–>Services–>Note Templates. Click Add Note Template.
The system provides three standard note templates: a Clinical note, a Grid Note and a Medical Note. Additional note templates can be configured if there is a need to customize note forms.
A Clinical note template is based off the PIE Note format, where three separate text fields capture the Purpose of Contact, the Interventions provided during service delivery and the Effectiveness of those interventions. The Purpose of Contact section is designed to link to the goals that are setup in the treatment section of the client record. Note: the three text fields can easily be renamed to see a different title for each section. That is handled by going to the Custom Labels screen in the Configure Desktop.
A Grid Note template is based off a grid format. It is designed to list goals from the treatment section of the client record in rows so that intervention and assessment keys can be assigned to each goal in a grid format. The keys are customizable per service code and configured in the List Configuration screen under the Services section.
A Medical Note template is a very simple format. It is designed to sync the Vital Statistic information from the medical section of the client record. There is also the capability to sync the medications and/or the DSM5 information from the medical section of the client record. To link the medications and the diagnosis information, email a request to firstname.lastname@example.org. The template provides a default long text box. Additional fields can be added to support a particular agency's version of a medical note by going to the custom fields screen in the Configure Desktop.
The default templates can be renamed with a specific title for a note that users will identify with. A new note template can be added if a modification is needed to any of the three default templates in order to meet your documentation requirements. With any note template, whether the defaults or a new one, users have the flexibility to add custom fields and/or rename any of the default labels. This expands the system’s ability to support a particular agency's specific note forms. There is no limit to the number of templates that can be created.
Give the template a description. This will be the common name for this note format, meaning this is how the note will be referenced in the drop-down selection list for note templates. Select a Note Type.
The Multi-day checkbox should be used when needing to capture multiple time events on a note; whether multiple dates of service, such as on a weekly or monthly note, or multiple start and end times within a single day. If this is not checked, then the system will only allow one time entry per date of service. Users can control which note templates are active, and therefore eligible for notes to be written against. If the template is not active, it is not visible in the notes desktop and a note cannot be written against that form. The clone button can be used to copy one template to another.
This is most useful when there are a lot of custom fields configured to a template and several of the fields need to be modified. It may be important to preserve the original template and create a new one to reflect the modifications. In order to further customize the note, see the Custom Labels and Custom Fields sections of the user guide.
A note template may be set as the default template for a corresponding service. This is recommended to ensure that the note-writers are completing their documentation against the correct note type. Without a default note template set per service, the note-writer is forced to choose the template to write their note upon; leaving room for error. To set the default, go to Configure–>List Configuration–>Services–>State Services.
Find the service in the list and then set the default template accordingly.