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 Note from the left-hand menu.
Accessing the Treatment Note section for the selected client
Step 2: Creating the Treatment Note
Click the Create Note button on the right.
Clicking the Create Note button to start a new treatment note
A drop-down list will appear with 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.
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).
Manage Quality of the note if applicable.
Treatment notes action button
Step 4: Attaching a Case to the Treatment Note
If there are no existing cases for the client, you can create a new one. Click Add a 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.