Where can I access my documentation for a client / session

This article applies to Therabill's custom documentation system only.  This article does not pertain to Simple Notes in Therabill.

You created a bunch of notes using Therabill's custom documentation system and now you want to know where to access them.  You can actually access your notes a few different ways.  You can access it directly from the session or from the client medical record.  There is also a method for viewing a bunch of notes for a patient at one time.  We will go over the various methods below.

Accessing a single note by date of service (session)

If you are looking for a particular note on a specific date of service then you can access that note from the edit session form.  There are a variety of ways to get to the edit session form for a particular session.  In general, you access the edit session form using the blue pencil that is associated with a session (for example, on  your dashboard, your schedule (under Schedule in the top green navigation bar) and in a variety of other places.

Once you have the edit session form open (see image to the right) for the session you want to view the notes on, you can access the note on it in a few different ways.

1. Click the printer icon  at the top of the edit session form (see image to the right, red arrow).  This will give you the ability to print the note out to a PDF form.
2. Click the Filing tab at the top right of the edit session form (see image to the right, blue arrow).  Here you can see a list of all documents (including CMS-1500, simple notes, attachments, and documentation) associated with the session.  You can also fax or e-mail out the documentation from the filing tab.  To send out the documentation by fax or e-mail, click the send icon  associated with the document you want to send.
3. If the session is not already finalized:  Then you may also want to view the note through the documentation tab.  Be careful here though, because the documentation tab will allow you to edit the note (if it is not finalized).  If the session is already finalized, then there will not be a documentation tab and you will need to use one of the other methods to view the note.

Accessing all notes for a client

Therabill also gives you the ability to access all notes that you have entered for a client through the client.  There are actually several ways to do this. 

Through the Client Medical Record

1. Click Clients in the top navigation bar.
2. Find the client in  your client list and then click the edit icon  for the client.

The edit client form (also referred to as the medical record or client chart) will open. At the top of the edit client form, click the Filing tab (image to the right).  On the filing section of the client, you will see a list of all sessions for the patient. You can click on the All or None links to select or unselect all of the sessions in the list. The select action dropdown will let you choose Print Selected, you can then press the Go button to print all of the documentation available for that client. You can also limit the sessions that you see by using the DOS (date of service) boxes and entering the start and end dates that you wish to see.

Each session listed will show the date of service, the provider, documentation status, icons to perform actions on a single session's documentation. A red outline around the session indicates that the session is not finalized. If the session has been finalized, the red outline will not be present. The documentation status column will show the name of the note for that session, or the text Multiple Notes if more than one note is available for that session. Cancelled sessions will show the text Cancelled. A session that has not yet started to be documented will show the text Not Started. After the documentation status there is a series of three icons. The first is the PDF icon. Clicking on it will open a PDF of the notes for that session. The green send icon will let you email or fax the notes for that session. The PDF and Send icons will not be present if there is no documentation entered for that session. The blue pencil edit icon will let you jump to the edit session form for that visit.

Using the Client Timeline

The client timeline is a 'beta' feature that gives you a visual of events over time for the patient.  While it is not the best way to access the notes, we do want to let you know that it is there.  To open up the timeline, click the timeline icon at the top left of the Client Medical Record (see image above, blue arrow).  The client timeline will show various events (in addition to documentation).  You can narrow down the events being displayed by unchecking events on the left hand side of the timeline.  For information on using the timeline, please see: the patient timeline.   

Using Documentation History

If you want to see all notes over time for a patient, then you will want to use Documentation History.  The documentation history can be accessed in a few ways.  One way to access it is through your client list (click Clients in the top green navigation bar of Therabill).  Find the client in your client list and then click the tools icon  associated with the patient.  In the menu that appears, click on the Documentation History option.  For instructions on using the documentation history, please see: Patient Documentation History.

Viewing all sessions that have notes and/or that are finalized.

If you want to see sessions (system wide, multiple providers) then you will want to use Documentation Search. The documentation search feature is available from your dashboard by clicking the Doc Search button.  For information on using Documentation Search, please see: finding and searching for notes in  Therabill.