In AutoNotes, the "Basic Individual Progress Note" template offers flexible customization to better suit your clinical documentation needs. This guide will walk you through the process of accessing and adjusting the template settings to optimize your documentation process.
Accessing Template Settings
Open the Template:
Navigate to the "Basic Individual Progress Note" template within AutoNotes.
Enter Settings:
Look for the "switch" icon located at the top right of the template. Click on this icon to open the template settings.
A popup titled "Configure Basic Individual Progress Note Template" will appear.
Customizing the Template
The settings popup allows you to tailor several aspects of the progress note. Here's how to use each option:
Client Pronouns: Toggle this option on or off to include or exclude client pronouns in the progress note. This helps personalize the note while maintaining respect for client identity.
Risk Assessment: Enable or disable the risk assessment section based on the needs of the session or client requirements. This section is critical for documenting any potential risks associated with the client.
Modalities: Turn this setting on to include modalities used during the session or off if this detail is not needed. Modalities might include therapeutic techniques or interventions applied.
Additional Instructions: You can add specific instructions that will appear in every note. For example, turning this on and setting it to "start every note with 'the clinician met with the client as scheduled'" ensures that each note begins with this standardized sentence.
Diagnoses Selection: Choose which diagnoses to include in your progress note: primary, secondary, and tertiary. This feature allows for detailed clinical documentation tailored to the client's needs.
Customize Your MSE (Mental Status Exam): This option lets you customize the categories and selections of the Mental Status Exam. You can replace the default options with your own, which allows for more precise and relevant mental health assessments.
Saving Your Customizations
After making your adjustments, click the "Save" button in the popup. This ensures that all your changes are applied to the template.
The template will then be updated to reflect your customizations, making it ready for use in documenting client sessions.
Customizing the "Basic Individual Progress Note" template settings allows you to adapt your documentation to meet specific clinical requirements and personal preferences, enhancing the accuracy and usefulness of your notes. By taking the time to configure these settings, you can ensure that your progress notes are both comprehensive and compliant with your therapeutic approach. Remember to save your settings to apply your customizations consistently across your documentation.