Session Notes Overview

Creating a Session Note

To give you the most flexible workflow, there are three different places in Zencare where you can write your session notes:

• The Calendar view
• The Client account view
• The Workflow view

From the Calendar view

From the Calendar view select the scheduled session. This opens a Session Overview window. From here, select Create Note.

From the Client Account view

• Select Clients, then select the Client Account and finally select the View button.

• Open the Sessions & Notes tab. This will display a full list of sessions the client has been scheduled for.
• Click on the Create Note button next to the session for which you are writing the note.

From the Workflow view

• Head to the Workflow. In the left management bar, select Documents, and then Notes. Here, you will see a list of every note up until today. Select the Create Note button next to the session for which you are writing the note.

Using the Note Editor

When you open the Note Editor, you'll see a blank word processor-style canvas so you can start typing a freehand note right away if you would like. There are multiple style and formatting options available to use in the toolbar.

Along the left side you'll find the Session Summary, with details about the current session, service, client(s), therapist(s) and the client's next session if applicable. Use the arrow to collapse the sidebar for a more focused note-writing view.

Importing a previous note into the current note

If you would prefer to use your previous note as a starting point, you'll find a dropdown menu in the top right corner that allows you to choose either the most recent note, or from a list of earlier sessions.

In the event of an error, use the "Clear Content" button to delete any content in the note template but maintain the formatting, or "Start Over" to erase the template and return to the blank text editor.

Applying a note template from your Practice Templates

Once your clinic has set up one or more templates under Manage, Notes, then Practice Templates, you will be able to apply a template to your note from within the Actions section in the left sidebar.

When you add a template, you will have the option to append it to the start or end of what you have already written, or replace it entirely.

You now have the ability to apply multiple templates to a single note. Each time you choose a new template you'll be asked whether to append it at the start, end, or replace the existing content.

Associating documents to a session note

Documents must be first uploaded to a client's record. If you have a document of any sort that must be associated to a specific session, head to the Note for that particular session. On the left-hand control panel, you will see an Associated Files section at the bottom.

To upload a new file to the session, select Upload and find the file on your hard drive.

To associate an existing file to that session, you should first make sure that the file is uploaded to the client's account. If files exist, you'll be able to select it from the pull down menu. Once associated, this file will be available from the note, and the note will be available next to the file in the Documents tab.

Signing the note to finalize it

Notes Signatures allow you to create notes with a high level of accountability. By signing, you are stating "the note is complete" and locking the note down from any further accidental edits.

The only way to change a signed note would be to unsign it by selecting Unsign Note. A preview of the signature is also shown at the bottom of the window, along with the date and time of the signing.

Configuring Signatures

To include a signature for a therapist, go to the Settings view and select Therapists. If you are in a group practice select the desired therapist account and select Edit.

From the Update Therapist menu, select Include Signature. Next, select Choose an Image under the Therapist Signature section to upload an image of your signature. A preview of the signature will appear in the section below. You can modify the Signature Size using the slider above the signature image. You can select Remove Signature to remove the signature at any time.

Notes Statuses

There are several note statuses that can be listed in the Notes overview:

• Create Note: A note has not been created. Selecting this will take you to the Note Editor.
• See Note: A note has been created. Selecting this will allow you to see the note.
• Therapist Signed: The therapist has signed the note but other signatures may be required such as a supervisor.
• Supervisor Signed: The supervisor has signed the note but other signatures may be required such as the therapist.
• In Review: The note is waiting on review from another required signatory such as a supervisor.
• All Signed: A note that requires both a supervisor and therapist signature has had all relevant parties sign off on the note.

Supervisor Sign Off

Assigning Supervisors to Therapists

To configure an account so that it requires a supervisor's signature to sign off on notes, first go to Settings, select the desired therapist and select Edit. From the Update Therapist menu, select the check box next to Require Supervisor Signature.

To add a specific therapist, select the desired supervisor from the drop down box under Primary Supervisor. You can also add additional supervisors by selecting Add Supervisor. Select Update Therapist when finished.

Signing off as a supervisor

To sign off on a note as a supervisor, select In Review when selecting a session from the Calendar view.

In the note, simply select Sign Note just like you would normally. The supervisor signature will be added below the assigned therapist's signature.

Deleting and Restoring Session Notes

To delete a session note, select the note from the Sessions & Notes section of the Clients view. Then select Delete from the buttons above the notes list.

To restore any notes that have been deleted, navigate to the Deleted Notes tab and select Restore under Actions.

Exporting, Printing, or Downloading Session Notes

Occasionally, you may need to export your session notes off of Zencare. There are two ways to do this:

• Exporting a single note
• Exporting a range of notes

Export a Single Note

To export and print a single note, you will first need to open the note. Once you do, you will see two options on the left: Download as PDF and Print Note.

If you select Download as a PDF you will get a notification of the status of your download in the upper right hand corner. Once the file is ready, the file will download using the settings in your browser governing file downloads.

When you export or print a session note, it will contain your practice header, therapist information, and client information identical to your invoices and receipts. It will also contain:

• Session date
• Service
• Next Session
• Note Created
• Last Updated
• Attendees
• The Note
• Your Signature

Export a Range of Notes

To export a range of notes in bulk, first head to the Client Profile. Then, in the left side bar, select Client Export and a pop-up will open directing you to choose which sections you wish to include.

Be sure that Notes is selected. Select a Date Range and finally select Export.

You will receive a notification in the upper right hand side notifying you of a successful export. You will receive an email notification when the export is complete and available on the Exports page under Clients.

Handwritten Notes

The Handwritten Note feature allows you to attach notes written with a stylus to any Session or Non-Session Note.

To start a Handwritten Note, first open any Session or Non-Session Note. Once you have opened a note, select Add a Handwritten Note on the left hand side after saving the note as instructed.

The Handwritten Notes tool will open. From here you can write directly to the blank page using your mouse or a stylus. Tools to help you modify your note are on the left hand side, and include changing the Pen Size, Color, including Images and Erasing, Undoing, and Redoing actions. You can manually Add Pages from the bottom left. Select Save and Close to finish.

The options included in the tools menu are as follows:

• Pen: Your writing tool for the note. You can adjust the size and color of the pen.
• Eraser: The eraser allows you to erase areas of the note you've written. Note: clicking on it does not delete elements from the page, it simply allows you to erase areas as needed.
• Delete: Using this tool you can select elements on the page to delete them. Use this instead of the eraser tool when you want to fully remove content from the page.
• Move: If you click on a page element with this option selected, you can move, resize and rotate it.
• History: This function allows you to see the Note History — a list of all actions taken in the note since opening it. Note that this history is only kept for the duration of your current editing session.
• Revisions: Permanently stored previous versions of your handwritten note. You can select a previous version of the Handwritten Note and open it.
• Notepad: This option will turn the note writing area into a lined paper background to help you write handwritten notes as if being written on paper.
• Image: This tool gives you two options: Upload an Image or Import a Saved Template.
• Undo/Redo: Select these two arrow buttons to go backwards and forwards through your Session History.

Using Templates and Images in Handwritten Notes

Templates allow you to easily use and reuse the same elements for all of your Handwritten Notes. To create a Handwritten Note template, go to Manage and then Handwritten Notes. In this area you can upload images to be used as templates, or create templates using the Handwritten Notes editor itself.

Select the plus (+) button in the top right corner. You will see two options: Upload an Image or Import a Saved Template (to create from scratch using the editor).

If you select Upload an Image, you'll be prompted to upload an image file from your device. After selecting an image, a preview will open and you will be prompted to name your template. Name the template and select Save.

Managing Handwritten Notes

After you've written and saved a Handwritten Note, you can access it again at any time by opening the Session Note of its origin. Open the client's profile and select the note from the client's Sessions & Notes. You will see any Handwritten Notes in the sidebar of that Session Note.

Selecting the dotted icon next to the name of the Handwritten Note in this sidebar gives you the option to View, Edit, Remove and Rename the Handwritten Note.

If you wish to print or export to PDF a Session Note that has a Handwritten Note associated to it, a new confirmation window will appear asking if you would like to include the Handwritten Note in the export or print out as well. Simply select Yes, Include Handwritten Notes to include them if needed.