Notes allow you to quickly and easily update client charts with information concerning your client's treatment from intake until discharge.
Due to medication management, prescribers have unique documentation needs. Grow Therapy aims to simplify the process by automatically populating required fields from the client intake form and progress notes that transfer information from the initial assessment.
Note types
📹 Video: Prefer video? This video from our Clinical Excellence team walks you through each section of the Initial Assessment and Progress Note for prescribers.
New Patient E/M or Initial Assessment: Use this note type following your client's first appointment.
New Patient E/M or Initial Assessment: Use this note type following your client's first appointment.
You must select an appointment to create this note type.
If your client has previously completed Grow Therapy intake forms, the information they provided will transfer from those intake forms to the relevant section(s) in this note. Check out this guide to enable, disable, or manage your intake form settings.
To save this note, you must complete all required fields and declare that any future treatment is medically necessary and that all of the information in the note is accurate.
After saving, there are "Submit the invoice" or "Submit later" options. If you submit the invoice, the note will be added to the client's chart, and an invoice will go to the Grow Therapy billing team for processing. Meanwhile, if you choose the "Submit later" option, only the note will be added to your client's chart.
Established Patient E/M or Progress: Use this note type to update or expand on an existing treatment plan.
Established Patient E/M or Progress: Use this note type to update or expand on an existing treatment plan.
You need to select an appointment to create this note type.
Several sections you completed in the Initial Assessment will transfer to the progress note, saving you time completing your documentation.
To save a progress note, you must provide all required fields and declare that any future treatment is medically necessary and that all of the information in the note is accurate.
After saving, there are "Submit the invoice" or "Submit later" options. If you submit the invoice, the note will be added to the client's chart, and an invoice will go to the Grow Therapy billing team for processing. Meanwhile, if you choose the "Submit later" option, only the note will be added to your client's chart.
SOAP: This note type ensures consistent, organized documentation and clearly communicates important information in the repeatable Subjective, Objective, Assessment, and Plan format.
SOAP: This note type ensures consistent, organized documentation and clearly communicates important information in the repeatable Subjective, Objective, Assessment, and Plan format.
Subjective (S): This section includes the patient's reported symptoms, feelings, and experiences. It captures the patient's perspective on their condition and any relevant history.
Objective (O): This section contains observable and measurable data collected by the healthcare provider. It includes physical examination findings, vital signs, and results from diagnostic tests.
Assessment (A): In this section, the healthcare provider provides their professional interpretation of the subjective and objective data. It includes the diagnosis or differential diagnoses.
Plan (P): This section outlines the treatment plan, including any prescribed medications, therapies, follow-up appointments, and patient education.
Chart: Use this note type to add information that does not fit the other note types. The contents of a chart note are appended to the timeline on a client's chart.
Chart: Use this note type to add information that does not fit the other note types. The contents of a chart note are appended to the timeline on a client's chart.
Discharge Summary: Use this note type when you stop working with a client, including the end of treatment or a referral to another provider.
Discharge Summary: Use this note type when you stop working with a client, including the end of treatment or a referral to another provider.
You can only create a discharge note for clients that do not have future appointments.
Discharging a client archives them.
Add a note to a client chart
Add a note via an invoice
To add a note to an invoice:
Navigate to Appointments via the sidebar navigation.
Select either the Unsubmitted or Expiring tab to review pending invoices.
Select the Submit Invoice option next to the desired appointment.
Fill out the note, ensure that you close it at the bottom of the page by checking the declaration checkboxes, and then select the Submit button.
🌟 TIP: The note type defaults to the most appropriate for the kind of appointment held, such as a Progress Note for a Follow-Up appointment. Ongoing note types, such as a Progress Note, will also auto-populate with information from your last submission to make recalling client progress easier.
If you need to swap the note type of the appointment, select the desired note type from the drop-down at the top of the notes area.
Finally, on the last screen, confirm the invoice information and select either the Submit option, which sends the invoice to the billing team for processing, or use the back arrow to leave the invoice process. Your note and invoice information are saved automatically. You can come back and submit it later.
🌟 TIP: Once you submit your notes as part of the invoicing process, you only have 24 hours to make additional changes. If more than 24 hours have passed, you must add a Chart Note addendum by following these steps.
Add a note to a client chart
To add a note via a client chart:
Navigate to Clients via the sidebar navigation.
Select a client to open their client chart.
Select the Overview tab beneath the client's name. Locate and select the Add Note option in the "Timeline" section.
Select the desired note from the Note Type dropdown menu and select Next. Certain note types, such as a Progress note, must also be associated with a specific appointment to keep the client's treatment information organized.
Fill out the note details and select the action button in the upper right. Multiple versions exist based on your note type. For example, a Progress Note might say Submit or Continue to Invoice, while a Chart Note will show Submit Note, and a Discharge Summary will show Save & Archive.
🌟 TIP: Ongoing note types, such as a Progress Note, will auto-populate with information from your last submission to make recalling client progress easier.
If you selected a note type associated with a specific appointment and related to ongoing treatment, you can use the note information to submit an invoice quickly. Confirm the invoice information and select either the Submit option, which sends the invoice to the billing team for processing, or use the back arrow to leave the invoice process. Your note and invoice information are saved automatically. You can come back and submit it later.
View or Edit a previous note
All saved notes are displayed in the "Timeline" section of the client's page. Individual notes are also accessible via the related appointment invoice.
View or edit via an invoice
To view or edit a note via an invoice:
Navigate to Appointments via the sidebar navigation.
Select the Past tab to review invoiced appointments (e.g., Submitted).
Search for and select the desired past appointment.
Scroll to the notes section and select the View Note link. Multiple versions exist based on the note type associated with the invoice.
After the note displays, you can view it or select Edit in the upper right to make changes. If the edit option is greyed out, too much time (>24 hours) has passed to update the note. Learn more about amending notes in this article.
View or edit via the client chart
To view or edit a note via the client chart:
Navigate to Clients via the sidebar navigation.
Select a client to open their client chart.
Search for and select the desired chart note or appointment note.
After the note displays, you can view it or select Edit in the upper right to make changes. If the edit option is greyed out, too much time (>24 hours) has passed to update the note. Learn more about amending notes in this article.