Client Notes

Client notes help you provide consistent, personalized service. This guide covers recording and accessing client information.

Types of Notes

Session Notes

Notes specific to each appointment:

• What was done during the session
• Client feedback
• Observations
• Follow-up needed

Client Profile Notes

General information about the client:

• Preferences
• Medical considerations
• Communication preferences
• Long-term goals

Adding Session Notes

During Completion

When you complete an appointment:

After Completion

If you need to add notes later:

1. Find the appointment in history
2. Click Add/Edit Notes
3. Enter your notes
4. Save

Quick Notes

For brief observations during or after service:

1. Open the appointment
2. Click Quick Note
3. Type your note
4. Save

Quick notes are timestamped and appended to the session.

What to Include

Recommended Information

Good session notes include:

What to Avoid

Do not include:

• Personal opinions about the client
• Information not relevant to service
• Sensitive information inappropriately
• Unprofessional comments

Viewing Client History

Accessing History

To see a client's past notes:

What You Can See

Depending on permissions:

• Notes from your sessions
• Notes from other therapists (if allowed)
• General client preferences
• Booking history

Filtering History

Filter client history by:

• Date range
• Service type
• Therapist (if viewing all)

Client Preferences

Documenting Preferences

Record ongoing preferences:

• Pressure preference (light/medium/firm)
• Communication style
• Scheduling preferences
• Product sensitivities

Accessing Preferences

Preferences appear:

• On the appointment detail
• In the client profile
• In the notes section

Medical Considerations

Recording Health Information

If the client shares health information relevant to service:

• Document appropriately
• Follow your organization's policies
• Note any contraindications

Accessing Health Notes

Health-related notes may:

• Have special visibility
• Require acknowledgment
• Be highlighted for safety

Note Templates

Using Templates

If available, templates help ensure consistent notes:

1. Select a template when adding notes
2. Fill in the required fields
3. Add additional information
4. Save

Common Templates

Templates might include:

• Standard session summary
• First-visit intake
• Follow-up appointment
• Specific service templates

Searching Notes

Finding Information

Search across client notes:

1. Go to Clients or Search
2. Enter search terms
3. Filter by note content
4. View matching results

Search Tips

• Use specific terms
• Search for service names
• Look for dates
• Try multiple search terms

Privacy and Access

Who Can See Notes

Note visibility depends on settings:

Client Access

Clients may:

• Request to see their notes
• Have portal access to notes
• Receive summary after visits

Check with your administrator about client note access policies.

Best Practices

Timeliness

• Add notes immediately after sessions
• Don't rely on memory
• Complete notes before next appointment

Consistency

• Use similar format each time
• Include key categories
• Be thorough but concise

Professionalism

• Write as if the client will read it
• Stick to relevant facts
• Use appropriate terminology

Confidentiality

• Don't discuss notes casually
• Lock your device when stepping away
• Follow privacy policies

Troubleshooting

Can't Add Notes

If you can't add notes:

1. Verify you have permission
2. Check if the appointment is completed
3. Ensure you're not in read-only view
4. Contact administrator

Notes Not Saving

If notes won't save:

1. Check internet connection
2. Copy notes as backup
3. Try refreshing and re-entering
4. Report the issue

Missing History

If client history seems incomplete:

1. Verify the client record
2. Check date filters
3. Ask about note visibility settings
4. Contact administrator

Next Steps