Clinical documents

The Documentation tab on a patient's chart lists every clinical document written for the patient: evaluations, re-evaluations, daily notes, plans of care, progress reports, recertifications, discharge summaries and patient forms. Each document belongs to one episode of care and takes its discipline, such as speech therapy (SLP) or occupational therapy (OT), from that episode. To see the documents of many patients at once, use Documentation across patients. When your clinic offers applied behavior analysis (ABA), an Assessments tab beside the documents holds the learner's ABA assessments.

Find a document#

Documents list newest first by their date. Click Filter above the list and add a filter to narrow it:

• Date shows documents dated within a range of days.
• Type shows some kinds of document, such as only evaluations.
• Episode and Discipline show the documents of an episode or a discipline.
• Status shows drafts or signed documents.

Remove a filter with its X.

Click a document's date to open it.

Start a document#

1. Open the patient's chart and click the Documentation tab.
2. Click New Document.
3. Choose the Episode. When the patient has only one open episode, it is already chosen.
4. Choose the Type.
5. Check the Template. Your default template for the episode's discipline and the document type is chosen for you; otherwise the clinic default is. You can pick any other published template that fits.
6. Set the Document date: the date of service, or the date of a document written without a visit.
7. Click Create Draft. The new draft opens right away.

If the patient's episodes or the templates cannot be loaded, the window says so and offers Try Again; the fields show once they load. A template you picked stays chosen if the template list refreshes while the window is open.

The document is in your name. To write it for another provider, turn on Write it for another provider and choose the provider. This option appears only for users who can write documents for every patient, such as clinic admins. Only active providers who practice the episode's discipline are offered.

If you have no provider profile, or yours does not include the episode's discipline, the window says so and the Provider field is required: Create Draft stays off until you choose one. If your role cannot write documents for other providers, ask an administrator to add or update your provider profile in Setup.

Templates stay as they were#

A document keeps the exact version of the template it started on. When someone changes the template in Setup under Templates and publishes it again, documents already started keep their sections and questions. New documents use the newest published version. A template that documents were written on can be deactivated, but not deleted.

Write a draft#

The document shows each section of its template with the fields the template defines: text, choices, numbers, scales, tables and more. Goal sections list the plan of care goals (see Daily notes); sections for treatment codes, diagnoses and signatures show where those parts will appear.

• Drafts save as you type. A few seconds after you stop typing, and whenever you leave a field, the draft saves. The bottom left of the window shows Unsaved changes, Saving or the time of the last save.
• Save, right beside that status, saves right away, as a checkpoint.
• A field with an explanation shows a question mark after its label; click it to read the explanation.
• The More actions menu (the three dots) at the bottom right holds the less frequent draft actions: Add Section, Add Section From an Earlier Document, Reorder Sections, Draft History, Print Draft and, last, Discard Draft. Close and Sign sit beside it.
• Formatted text boxes have a toolbar: undo and redo, bold, italic and underline, Clear formatting for the selected text, bulleted and numbered lists, Increase list level and Decrease list level to nest list items, and Insert field. The signed PDF prints the text without its formatting.
• If the connection drops, your typing stays in the window and NeatPractice keeps trying to save it. The message Not saved yet, trying again shows until it succeeds.
• If you close the window while a save is still failing, NeatPractice asks before closing, because closing would lose the latest changes.

A draft can be changed by the person who started it, and by the provider named on it when someone else started it for them. Everyone who can see the patient's documentation can open a draft to read it.

Someone else's draft#

When you open a draft you cannot change, a Read-only note at the top says who can edit it, for example "Only Jordan Example, SLP or Sam Example can edit this draft." The fields show as text and the only action is Close, unless your role allows one of the actions below.

Take over a draft#

When a provider is away and their draft needs finishing, someone whose role has the Take Over permission for notes can take it over:

1. Open the draft and click Take Over Draft.
2. Read the confirmation and click Take Over.

You become the draft's author and can edit and finish it. If you are a provider of the draft's discipline and the draft is not part of a visit, you also become the provider who signs it; otherwise the provider named on it still signs. The previous author can no longer edit the draft and gets a notification. If they had it open, their window switches to read-only and their unsaved typing is not kept. The change is written to the security audit log as Clinical draft taken over, with who took it over and from whom.

Edit any draft#

A role with the Edit Any Draft permission for notes can change any draft in the clinic in place, without taking it over. A note at the top reminds you whose draft it is. Every save is logged under your name, and the document shows Last edited by with the name of whoever saved it last when that is not the author. Editing someone else's draft does not let you discard it or sign it: only the provider named on it signs.

If you and the author both have the draft open, the second save shows This draft was saved somewhere else, as described below, so neither of you overwrites the other by accident.

Review a colleague's draft#

A supervisor whose role has the Review Draft permission for notes can correct a draft before its author signs it, on the patients the permission reaches (with caseload access, the supervisor's caseload, which includes their supervisees'). The Clinical Supervisor and Behavior Analyst roles have it for their caseload. A Reviewing a draft note at the top reminds you whose draft it is.

Your saves are kept under your name, and the document shows Last edited by. The first time you save someone else's draft, the author and the provider named on it get a notification, and the edit is written to the security audit log as Clinical draft edited by reviewer. A role with Edit Any Draft is treated the same way. A reviewer cannot discard or sign the draft: only the provider named on it signs.

Re-evaluation due date#

Evaluations and re-evaluations have a Re-evaluation due date beside the document date. Set it when the patient should be re-evaluated, for example when a payer asks for one at fixed times. Leave it empty when no re-evaluation is planned. Once the evaluation is signed, the date shows in the provider's due items on the schedule and, from 8 days before, in the Re-evaluations due widget on their dashboard. A newer signed re-evaluation of the episode replaces it with its own date, and a discharged episode no longer shows it.

Evaluation diagnoses#

When the evaluation's template has a Diagnoses section, it starts with the episode's diagnoses in claim order. Add, remove or drag diagnoses to reorder them, up to 12 for claims; the first four are the claim's default pointers. When you sign the evaluation, its list becomes the episode's list. A code new to the episode must be billable on that day.

Medications#

When the template has a Medications section, it shows the patient's active medications and the last medication review from the chart. The section cannot be typed into: click Open Medications to update the list on the chart, then come back to the note. When you sign, the note keeps the list as it stood at that moment, so later changes on the chart never alter a signed note. See Medications.

Attach files#

Every document has an Attachments list. While it is a draft, click Attach File, choose the file and its category, and click Upload. The file is stored with the patient's chart documents, checked for malware the same way, and opens from either place. While the document is a draft, a file's row menu offers Edit details to fix its name, category, description or date, and Remove from this draft to take off a file attached by mistake; the file stays in the chart's Documents. A signed document keeps its files but takes no new ones. A list longer than 50 files shows Previous and Next under it.

To use an evaluation written outside NeatPractice, start the evaluation, fill in the header, attach the file and sign it. Once a file is attached and checked, the template's required fields become optional for that evaluation, and the signed copy lists the attached files.

When a draft was saved somewhere else#

If the same draft is open in two windows, on two devices or by two people, the second save notices that the draft changed after it was opened. NeatPractice stops saving and shows This draft was saved somewhere else. Your typing stays in the window. Choose one:

• Keep My Version saves what you typed over the other version.
• Load Saved Version shows the saved version and drops what you typed in this window.

Discard a draft#

To remove a draft started by mistake, open it, choose Discard Draft in the More actions menu (the three dots at the bottom), then Discard. Only the draft's author and the provider named on it can discard it. The draft leaves the chart. NeatPractice keeps it in the clinic's records and logs who discarded it and when.

Sign a document#

When the draft is complete, click Sign at the bottom of the document. See Sign and co-sign notes for what signing asks and what it does.