Creating Notes

Overview

Creating comprehensive clinical notes is essential for tracking client progress, meeting insurance requirements, and communicating with other professionals. This guide covers the fundamentals of creating effective notes in Praxis Notes.

Types of Notes

Praxis Notes supports several types of clinical documentation:

• Session Notes: Document individual therapy sessions
• Progress Reports: Summarize treatment progress over time
• Assessment Notes: Document initial and ongoing assessments
• Treatment Plans: Outline goals and intervention strategies

Creating a Basic Session Note

1. Navigate to the client's profile
2. Select "New Note" or "New Session"
3. Complete all required fields in the form
4. Add supporting details and observations
5. Use the "Generate" feature to format your notes
6. Review the generated note for accuracy
7. Save as draft or finalize for submission

Best Practices for Note Writing

• Be specific and objective in your observations
• Use behavioral terminology consistently
• Document measurable goals and progress
• Include start and end times for all sessions
• Note all participants present during therapy
• Describe interventions used and client responses
• Avoid subjective language or interpretations

Formatting Guidelines

• Use clear, concise language
• Organize information logically
• Include relevant data points
• Maintain professional tone
• Proofread for errors
• Use appropriate medical terminology