11 How to Create a Note Template

The system provides three standard note types: Clinical note, Grid Note, and a Medical Note.

• Clinical note: this template is based on 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. These fields can be re-labeled using custom labels.
• Grid note: this template is based on 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.
• Medical note: this template is designed to sync the vital statistics 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. This template is highly configurable.

Creating a Note Template

1. Click on Configure
2. Click on List Configuration
3. Select Notes→ Note Templates

4. Click on Add Note Template
5. Enter a Description for the template
6. Select the Note Type
7. Click on the Save button

Managing Note Templates

'One Key Per Key Set' only applies to Grid note templates. When this checkbox is selected for a particular note template, only one note key (ex. I=Independent, VP=Verbal Prompts, Etc.), can be selected for a set of keys ('Interventions' for instance). If the checkbox is not selected for a particular note template, then multiple keys can be entered for a set of keys.

You 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.