Daily notes

A daily note documents one visit. Besides the fields of its template, a daily note can record the goals you worked on, reuse what you wrote last time, and grow or shrink by section. Everything on this page applies to drafts; a signed note never changes.

Write a note from a visit#

1. Open the visit from the patient's Visits tab.
2. Click Write Note. The note is tied to the visit: its episode and date of service come from the visit.
3. Check the Type. It starts on what the appointment calls for (an evaluation for an evaluation appointment, a daily note otherwise); you can pick a daily note, evaluation, re-evaluation, progress report or discharge summary.
4. Check the Template and click Create Draft.

Once a note exists for the visit, the button reads Open Note and opens it.

A Diagnoses section on a daily note lists the visit's diagnoses, or the episode's when the note has no visit, for reference. Change them on the visit or the episode; only an evaluation edits its diagnoses in the note.

Care continuity#

While a daily note written from a visit is a draft, Care continuity near the top shows where care left off:

• Last visit: the patient's previous visit in the same discipline (when, with whom and which codes), whether its note is signed, and each goal that note addressed with its result and notes. Goal results show only when you may read that note; otherwise you see the visit alone.
• Next appointment: the next booked appointment in the discipline and its providers.

The panel is for reference while you write and is not part of the note. Disciplines with their own session panel, such as ABA, show their version there instead.

Reminders for the next visit#

Any note written from a visit has a Reminders for the next visit section, for every discipline:

• Click Add Reminder to leave a short note for the patient's next visit in the same discipline, such as what to try first or what to ask the family. Only you can edit or delete your reminders, until someone dismisses them.
• From earlier visits lists the open reminders earlier notes in the discipline left, with the date of the note and its provider. Click the copy button to put a reminder on your clipboard and paste it where it belongs, or the dismiss button once it is handled. Dismissed reminders stop showing on later notes.

Reminders are never part of the signed note unless you paste their text into it. Each one, and who dismissed it, is kept in the audit history.

Pick lists#

When your clinic has pick lists for daily notes, or for the note's template, a Pick lists section asks them below the template. A required one must be answered before you can sign, and a list with Several answers off takes one answer. Your answers save when the note saves, signs, prints or closes, and print with the signed note.

Note elements#

Your clinic can require medical necessity elements on every visit note, such as start and end times or units on every code (see Note elements). A note missing one shows it in the checks before signing and cannot be signed until it is fixed.

Goals from the plan of care#

When the note's template has a goals section, the note starts with the active goals of the episode's plan of care, in the plan's order. The section says which plan of care the goals came from. Short-term goals sit indented under their long-term goal, with their target and baseline.

For each goal:

• Leave Addressed checked for goals you worked on and enter the Result: a percent, a number of trials, times per session or minutes, depending on how the goal is measured. Goals measured by cueing only ask for the Cueing level.
• Pick the Cueing the patient needed and add short Notes if you want.
• Clear Addressed for goals you did not work on. They stay in the list, so you can check them again later.
• Drag a goal by its handle to change the order.

A goal added to the plan of care after you started the note shows up at the end of the list, not addressed.

Current target and trend#

Under each goal you check as addressed, the note shows the goal's Current target, its Last result and date, and a small trend of its results over the last 90 days. The value you are typing, or the trials you are counting, joins the trend as a hollow point as you enter it, so you can see how today compares before you sign.

Count trials#

Goals measured by percent accuracy or by trials can be scored attempt by attempt instead of typing a result. Turn on Count trials under the goal, then after each attempt tap the plus on Correct, Incorrect or Prompted. Each outcome shows its count between its minus and plus, and the buttons grow on a tablet; with the counter focused you can also press C, I or P, and Backspace to undo.

• The result becomes correct out of attempted, with the total always shown: "7/10, 70%" for a percent goal, "7/10 trials" for a trials goal. Prompted attempts count toward the total but not as correct.
• Pick a cue (Ind, Min, Mod or Max) to tag the attempts you record next, so a session with mixed cueing keeps each level apart ("2 prompted; 5 minimal cues, 3 moderate cues").
• The minus on an outcome takes back that outcome's last attempt; Undo takes back the last attempt of any kind.
• With no attempts recorded the goal has no result, never 0%. Turning Count trials off clears the attempts so you can type a result instead.

The signed note keeps every attempt. To correct a count after signing, add an addendum.

Activities performed#

When the note's template has an activity flowsheet, record each exercise or drill with its dose, support and the patient's response, see the last session's values beside it and copy the last session forward. See Activity flowsheets.

Goal progress on progress reports and discharge summaries#

A progress report or discharge summary with a goal progress section lists the same goals with what the daily notes measured during the reporting period:

• the First and Last result, with their dates,
• the Average over the notes that reported the goal, rounded to a whole number,
• a chart of every result against the goal's target, with a trend badge. Results from notes that are not signed yet show as hollow dots. See Goal progress over the period.

When the report has a Reporting period section, its From and Through dates set the period: the goal progress updates as you change them, and the signed report and its PDF keep the same period. A Through before the From shows no measurements until you fix it. Without those dates, the period runs from the day after the episode's previous progress report (or from the plan of care, when there is none) through the date of the report. Choose the Status of each goal yourself; NeatPractice never sets it from the numbers. Clear Include for goals you leave out of the report.

Copy from the last note#

Fields that had an answer on your last note of the same type and discipline for this patient show a copy button right after their label. Click it to copy that answer into the field.

Copied answers carry a Copied from label with the date of the note they came from. The label goes away as soon as you change the field, so a reviewer can tell which parts of a note were carried over unchanged.

Add or remove sections#

Open the More actions menu (the three dots) at the bottom of the draft:

• Add Section adds an empty section from the clinic's published components that fit the note's discipline and type. Pick the Component and a Position: At the end (the default) or After one of the note's sections.
• The plus icon on a section's heading (Add section below) opens the same window with the position set to right after that section.
• Add Section From an Earlier Document opens the patient's earlier documents. Filter them by Discipline, pick a Document and a Section, check the preview and click Insert Section. The section comes in with its answers, labeled History with the type and date of the document it came from. Its answers are marked as copied until you edit them. If the note already has that section, the inserted one replaces it. The list shows the newest 100 documents; click Older and Newer to reach the rest. If the documents or a document's sections cannot be loaded, the window says so and offers Try Again.

To remove a section, click the trash icon on its heading and confirm. A note keeps at least one section.

To reorder sections, use the up and down arrows on a section's heading; each moves it one place. To arrange them all at once, choose Reorder Sections in the More actions menu, drag the sections (or pick one up with Space and move it with the arrow keys) and click Apply; Cancel leaves the order as it was. Only the order changes, never an answer. The new order is kept on this note only, never on the clinic's template, and is the order the signed note and its PDF show.

NeatPractice saves your typing before it adds, removes or moves a section, then reloads the draft.

Copy an evaluation or plan of care#

To start a new evaluation, re-evaluation or plan of care from an earlier one, signed or not:

1. In the Documentation tab, open the row menu of the document and click Copy Into New Draft.
2. Set the Document date and click Create Draft.

The new draft uses the same template version. Answers come across marked as copied, except dates and times, signatures, and the treatment plan (the plan of care sections and the treatment codes), which start empty. The new draft is in your name.