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Completing Charting Notes for Therapy

  1. Go to your Care Dashboard. 

  2. Open the Client Tab.

  3. Click on the Client.

  4. Select the specific session.

  5. Update the session status in the top left corner by clicking the Edit Status button.
  6. Navigate to the Notes tab to find the pre-drafted note template for the session.
  7. Complete each section of the charting note.
    1. Date, Time, Name, and Session # will be pre-filled.
    2. Time Spent in Session: Must be a minimum of 16 minutes to bill. Based on the billed session length (30, 45, 60 minutes). Sessions longer than 60 minutes will not be covered by insurance.
    3. Chief Complaint: Will be pre-filled by the Scribe. List the primary symptoms to be treated (e.g., anxiety, depression, ADHD). Must align with the diagnosis.
    4. Diagnosis: Suggested diagnoses will be pre-selected. To adjust, start to type the diagnosis; the ICD-11 code and name will appear.
      • At least one F-code diagnosis is required.
      • Be careful to avoid duplicate adjustment disorder diagnoses (e.g., avoid having both "adjustment disorder with anxiety and depression" and "adjustment disorder with anxiety").
      • Avoid "unspecified" diagnoses
    5. CPT Code: Select the appropriate code based on session length/type:
      • 90791 - Initial Assessment (up to 60 minutes in session)
        • Note: this is only used for intake sessions
      • 90832 - Psychotherapy, 30 minutes (16-37 minutes in session)
      • 90834 - Psychotherapy, 45 minutes (38-52 minutes in session)
      • 90837 - Psychotherapy, 60 minutes (53-60 minutes in session)
        • Note: Insurance does not reimburse psychotherapy beyond 60 minutes. If a session exceeds 60 minutes, still select 90837 and put a maximum of 60 minutes for "Time in Session"
      • 90846 - Family psychotherapy without the patient present (26-50 minutes in session)
      • 90847 - Family psychotherapy with the patient present (26-50 minutes in session)
    6. Mental Status: Will be pre-filled by the Scribe. Update to complete each area thoroughly.
    7. Risk Assessment: The default is "The client denied thoughts, intent, or plan to harm self or others." Update based on the client's current functioning.
    8. Summary of Session: Will be pre-filled by the Scribe. Add, edit, or supplement the drafted text to provide an overview of what was reported/addressed in session, including the client’s response to treatment.
    9. Treatment Outcomes: May be pre-fill by the Scribe. Ensure client's progress towards goals and outcomes is being documented here. 
    10. Treatment Goals/Objectives: May be pre-filled by the Scribe. Starting with the 2nd session, be sure to input specific treatment goals/objectives.
    11. Treatment Plan: The following statement will fill in for you: “Recommend weekly individual therapy with this provider using Cognitive-Behavioral Therapy (CBT) in order to address _______. Recommend 8-12 sessions, and at the completion of these sessions, it will be determined if treatment goals/objectives have been completed or if additional sessions may be needed.”
      1. Update the blanks, frequency of sessions, modality and length of treatment accordingly
    12. Signature Block: The below will fill in for you, please update with your signature block.
      • (Name)
      • (Licensure Type) Ensure your credentials (e.g., LCSW, LMFT) for all states are included.
      • (License Number) Ensure your license number for all states are included. 
      • Emora Health
    13. Save and Sign: Click Save (bottom right) to come back later or Save and Sign to submit. 

 

Key Reminders:

  • Timeliness: Complete notes within 24 hours if possible, and always within 72 hours of the session. 

  • Signatures: Always sign your notes once completed so they are ready for billing.

  • Credentials: Ensure your credentials (e.g., LCSW, LMFT) are included in your signature block.

  • Specific Goals/Objectives: Starting with the 2nd session, be sure to input specific treatment goals/objectives in the note.

  • Intake Forms: If the intake form does not populate, add a note stating "Intake form not yet complete by parent" or "Intake note in the chart."

  • Diagnosis Codes: Avoid duplicate diagnoses and unspecified diagnoses

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FAQs

What if a draft of the note is not created by the Scribe ?
If a draft of the note is not created or hasn't pre-populated with information from the session, there are a few things to consider:

  1. If the appointment recently finished, wait for a few more minutes so the Scribe can finish generating.
  2. If you accessed your appointment through the emora.gethealthie.com website, the Scribe may not have been activated. Moving forward be sure to access sessions via the Care Dashboard to ensure the Scribe feature is enabled
  3. If you joined via your Care Dashboard and waited more than 2 hours after the session, please reach out to Provider Success for further assistance.

What if the Client Background Form information does not pre-fill?
Indicate in your note that the Client Background Form is not complete or that it can be found on the client's chart, then continue your note.

What if I forget to sign?
Unsigned notes can delay billing and payment. You will be notified of unsigned notes in your daily email.

Which template should I use?
The auto-generated draft will already be in the accurate template, so no need to select one specifically. If it does not pre-draft, please use the following templates:

  • Initial Sessions - "Consult Note for Therapy"
  • Follow-Up Sessions (Child) - New Child Therapy Note (Enrolled after 9.18.2024)
  • Follow-Up Sessions (Adult) - New Adult Therapy Note (Enrolled after 9.18.2024)

What if I disagree with the suggested diagnosis?
Diagnoses are up to your clinical judgement of the client, so you are always welcome to update or delete the suggested options. To delete, click the dropdown and unselect the diagnosis.