Notes allow you to quickly and easily update client charts with information concerning your client's treatment from intake until discharge. You can make changes to your notes until you sign them. However, once you sign your notes, you cannot make additional changes after 24 hours. To add more information or make a correction, you must create a new note instead of editing the existing one.
Key Points
Notes allow you to track client progress during treatment.
Once a note is signed, usually during the invoice process, you have 24 hours to make additional changes before the note is locked.
To add information or make a correction to a previous note, you must add a new note, which must follow a specific "Addendum" format.
A downloadable "Tips for Writing an Addendum" is available here.
Before you begin
Late entries, addendums, or corrections to a medical record are legitimate and a fairly common occurrence in the documentation of clinical services. These notes are part of the client's official medical record and will be released with the designated record set when appropriate. Before you attempt to amend or correct a signed note on a client chart, it is essential to understand the difference between the update types and know the recommended format for each.
Late Entry: A late entry allows a provider to share additional information omitted from the original note. The late entry should be added as soon as possible and should only be entered by the person who wrote the original note. Think of this as something you forgot to include in the note and want to add now. You'll also need to write the date of service to which the late entry is related. These become part of the client's medical record and will be submitted as part of a record release with your original documentation of the service. Example:
Late entry on [date and time]: The client also reported during the visit on 11/3/23 that they completed the homework assigned during the last visit.
Addendum: An addendum is used when a provider needs to include new information unavailable at the time of the original entry. Sometimes, clients or guardians will contact us after a session to provide relevant information that they are now sharing. Rather than holding this for the next visit, it can be helpful to add it to the record. You'll also need to write the date of service to which the addendum is related. These become part of the client's medical record and will be submitted as part of a record release with your original documentation of the service. Example:
Addendum [date and time]: The client's mother contacted me after the 11/3/23 session to report that the client had not disclosed that she had been suspended from school for two days following an angry outburst last week where she verbally lashed out at a classmate using profanity and threats.
Correction: Due to the use of an electronic medical record, physical corrections or deletions of notes are not possible. Instead, providers may write a note to explain the incorrect information in the original entry and document the correct information. This note can also be used to clarify information. You'll also need to write the date of service to which the correction is related. These become part of the client's medical record and will be submitted as part of a record release with your original documentation of the service. Example:
Correction [date]: Documentation from the session on 11/2/23 included a report from the patient that they currently use marijuana daily. The patient clarified that he is using marijuana no more than 2x per week.
When is a signature required?
A signature is required when closing out all note types except a Chart Note. The signoff occurs during the "notes" step of the invoicing process. A signature is registered, and the 24-hour window for amendments begins when you hit the Submit button after declaring that the services you provided were medically necessary and that the information in your notes is accurate and complete.
Update an existing note
If less than 24 hours have passed since you signed a note, you can update the existing note. To update an existing note on a client chart:
Navigate to Clients via the sidebar navigation.
Select a client to open their client chart.
Ensure the Overview tab is selected beneath the client's name. Locate the desired appointment on the "Timeline" and select the associated note (e.g., Progress note) to open the notes view.
From the notes view, select the Edit button in the top right. If the option is greyed out, too much time has passed, and you must add a chart note.
In the edit mode, make the desired changes, scroll to the bottom to re-declare the note's need and accuracy, and then select the Save button.
Add a chart note
If more than 24 hours have passed since you signed and submitted a note to a client's chart, you must add a "Chart Note" to expand, amend, or correct the previously submitted information. To add a chart note to a client chart:
Navigate to Clients via the sidebar navigation.
Select a client to open their client chart.
Ensure the Overview tab is selected. Locate and select the Add Note button in the "Timeline" section.
Select Chart Note from the Note Type dropdown menu. Choose a date from the "Appointment" dropdown menu to attach the note to a specific appointment and select Next.
Fill out the note details and select the Save button in the upper right when the note is complete. The Before You Begin section above shows examples of the most common note addendums and corrections. Following this format will ensure all required information is included and easy to review.
Add a note via file attachment
If you have additional documents relevant to a client's appointment, you can attach them to individual appointments. This functionality enables to track important notes, addendums, and files pertinent to each appointment.
Navigate to Clients via the sidebar navigation.
Select a client to open their client chart.
Ensure the Forms & Files tab is selected beneath the client's name.
Locate and select the Add File option on the "Files" card.
Click the Select a file to upload option in the pop-out.
Select the desired file(s) from your device and click Open. The file(s) will now appear in the pop-out. From here, you can remove any accidental additions or rename any files you've included.
Provide the desired "File type" and "Appointment" information to associate and organize the uploaded information more precisely.
Finally, select the Upload button to confirm the attachments. The file will now appear in the client's timeline under the associated appointment.
Additional resources
For more details on late entries, addendums, and corrections, or if you need to print and complete a physical version of a note, check out the "Additional Resources" folder in your provider portal for resources from Grow's Clinical Excellence Team.
To access this folder:
Navigate to your provider portal.
Select your account name in the bottom left corner.
Select the Additional Resources option from the menu.
