Overview
Clinical Notes in PIMSY's Portal provide clinicians with a structured way to document client evaluations, track progress, and record clinical observations. Notes can include observations, treatment recommendations, and other relevant details, all stored securely within the client’s chart. By centralizing this information, PIMSY ensures that clinical notes are easily accessible for ongoing care, provider collaboration, and compliance with documentation standards.
Required Permissions and Prerequisites
- This article is in reference to our Portal
- Please assign the Create, Modify, View, and Delete permissions for the following rule(s):
- Note (Assessment)
-
Group Notes
Step-by-Step Instructions
Step 1: Navigating to Notes
There are a few ways to create notes in the Portal:
- From the Notes tab within a client chart
- From the Notes to Start tile on the dashboard
- From the Edit SAL appointment screen in the calendar
Step 2: Notes Tab of a Client Chart
From the top navigation menu, click Clients. Select a client from the list to open their client chart, then select the Notes tab from the dropdown. From the Notes tab, click the + New Assessment Note button to start a new note.
This button being exposed is subject to your companies configuration. If you do not see this button here, your site has this ability turned off.
Step 3: Notes to Start Dashboard Tile
From the Dashboard of the Portal, click on the Notes to Start tile. This tile will only be visible if there pending notes to be started based off previous SAL calendar appointments.
Select the applicable client/appointment and click the Create button to start the new note.
Step 4: Edit SAL Appointment Screen
From the top navigation menu, click on Calendar. Double-click on an appointment to open the Edit SAL window, then click the Note button.
Alternatively, you can access appointments from the Calendar widget panel on the left side of the screen. Click an appointment from the list and then click View to open it. From the Edit SAL window, click the Note button.
Step 5: Creating a Note
For this article, we will create a note from the Edit SAL window. Clicking Note will open the Note screen, automatically linking it to the appointment it was opened from.
In the Basic Details section, complete all required fields (Service Date, Start Time, End Time, and Primary Billing Code) along with any other relevant fields.
Check Telehealth Video or Telehealth Audio ONLY if the appointment took place via telehealth.
Check Inpatient if the appointment is inpatient.
Check Face to Face if the appointment was conducted in person.
Check Collateral Note if the note is a collateral note.
At the bottom, Note Tags, Client Tags, and SAL Tags can be updated at any point.
After completing all required and relevant fields, click Save to generate a Note # and officially create the new note.
Additionally, this action will queue the note to show in the Unrel. Notes dashboard tile until it is released. "Unreleased" means the note has not been signed off and can still be edited. Marking a note as "Released" locks it from further editing, attaches your digital signature, and indicates it's ready to be billed.
From this point in the documentation process until the note is released, staff can edit and save their work, exit, and return later to complete it. Data from the note will sync back to the SAL, so any edits must be made to the note - not the appointment.
The dropdown menu titled Select Tabs, at the top right top of the Note screen provides quick access to key areas:
- Substance Usage – Record and track substance use
- Medications – View and manage client medications
- Diagnosis – View and manage diagnoses
- Goal – View and manage goals and outcome measures
- Add Services – Add additional services
- Reference – Quick view of demographics, insurance, and service location info
- Team – Add and manage team members
- Misc. Q&A Tracking – Area for internal notes
These tabs can be brought down based on your need. Simply click the name of the tab and it will display among the top menu of the note.
You can also complete forms to the note by selecting them from the Forms dropdown. Completed forms will be highlighted in green for easy reference.
For faster documentation, click the PAISLY icon to generate a note narrative using our AI-powered narrative tool. For step-by-step guidance, see our article on How to Use PAISLY AI.