Creating and managing treatment notes in Rehab Guru is a straightforward process. You can use pre-existing templates, attach cases to notes, and organise your entries efficiently. Follow the steps below to create a treatment note for a client.
Step 1: Selecting the Client
Navigate to the Clients page and select the client for whom you want to create a treatment note by clicking View.
Accessing the client’s profile to create a treatment note
Once inside the client’s profile, select Treatment notes from the left-hand menu. On a smaller screen, these options show as tabs across the top of the profile instead.
Accessing the Treatment notes section for the selected client
Step 2: Creating the Treatment Note
Click Create note at the top right.
Clicking the Create note button to start a new treatment note
The New Treatment Note screen opens. Click the Select template drop-down to see all the available treatment note templates that you have cloned or created.
Select the template you want to use from the drop-down list. If you need to manage or edit your templates, click on Manage templates to return to the forms section.
Selecting a treatment note template from the drop-down list
Start writing your notes by following the prompts within the template. Any required fields will be marked with a red asterisk.
You will not be able to save the note until all required fields are filled out.
Adding and resizing text on a body chart
If your template includes a body chart question, click Click here to draw Body Chart to open the drawing tool. Use the Text tool (the T in the left-hand toolbar) and click on the chart to add a label, then type your wording.
To make a label smaller:
Select the hand tool at the top of the toolbar and click the text once so it is highlighted.
Open the size tool (the three vertical bars) and choose the thinnest option. The text shrinks to the small size. The middle and thickest options give medium and large text.
Double-click the text if you want to change the wording.
Each new text box is added at the largest size, so repeat these steps for every label you want small. Colour is set the same way using the colour swatch.
Once you click Save in the drawing tool, the body chart is stored in the note as an image. It cannot be reopened for further drawing, even in a draft note. To change it, delete the body chart from the question and draw it again.
Step 3: Saving the Treatment Note
Once you have completed the note, you can save it either as a Draft or Final:
Save as Draft: Allows you to edit the note later.
Save as Final: Locks the note and prevents further edits.
Options to save the note as a draft or final version
After saving, you can use the Actions button to:
Edit the treatment note (if saved as a draft).
Copy to new note: start a new note from this one, so you only change what is different.
Manage client cases: attach the note to a case, or change the case it belongs to.
Export treatment note: download a copy of the note.
Add to AI Chat: bring the note into an AI Chat conversation.
Treatment notes action button
Step 4: Attaching a Case to the Treatment Note
To attach a case, click the three dots next to the note and select Manage client cases. If there are no existing cases for the client, you can create a new one. Click Add case and enter a case name (e.g., Ankle Sprain) and any relevant notes or diagnostic codes. Then click Create.
Creating and attaching a case to the treatment note
Select the newly created case and click Attach to this case.
If a case already exists, simply select it from the list and attach the treatment note to the case.
Step 5: Managing Past Notes
When creating a new treatment note, any previous notes will move to the right side of the screen, allowing you to review past entries.
Viewing past treatment notes while creating a new one
You can choose more space to write by clicking the arrows to hide the menu bar, previous entries, and other interface elements.
Use the quick search option to filter notes by case or search for specific entries.
By following these steps, you can create, edit, and manage treatment notes for your clients in Rehab Guru, ensuring all client information is properly recorded and organised.