Intake Note

Once you have entered the client, you can begin documenting sessions.

Entering notes for existing patients

First select the client by clicking the name on the list in the Patient window..

From the Documentation menu select New...Intake.

By default, the Intake Note consists of three areas for recording data:

Clinical sections

The Intake Sections are displayed on the side menu or listbar under the Intake Note header. Click on a section name, such as Pervious Treatment, to open the corresponding screen.

Click on the caption bar labeled Other Sections at the bottom of the listbar, and then click a section to open a corresponding screen.

Click on the caption bar labeled Psychosocial History at the bottom of the listbar, then click a section to open it.

You do not have to complete all sections. Once you have familiarized yourself with the sections, you can determine which areas you want to address. You do not have to go to every screen, or fill in every field. However, since the symptoms and treatment goals pick lists are based on the diagnosis(es) you enter, it is generally best to record the patient's diagnosis before addressing the symptoms and goals.

Information entered in fields is automatically saved when there is no Ok or Close button to click.

Spell Check

Click the Spell Check button on the toolbar, or select Spell Check from the File menu to spell check fields in the documentation sections. Be sure your cursor is in the field that you want to check.

Screen Tips and Help

Context Sensitive Help is available from every screen.

To access Help:

•	Click on the help icon in the upper right of the screen, or press F1.

See Also

Using the listbar

Intake Sections

Generate and print your note

Edit Intake Note

Customizing Notes

Custom Screens

Other Note Sections