Clinical Notes & Care

Progress notes, treatment plans, outcome measures, co-signatures, discharge, and records release.

• Write and sign clinical notesClinical notes live on the client's Notes tab. Start one from the New note button, a completed visit, or the calendar; write it in sections from a built-in layout or your own template while it autosaves; then sign and lock it with your name and credentials. A signed note cannot be edited — add an addendum or void it with a reason. Notes by associates wait for a supervisor's co-signature. Psychotherapy notes are a separate, author-only record that never leaves the practice in an export. Signing a note linked to a visit also captures the visit's charge.
  4 min
• Add diagnoses to a client's recordDiagnoses live on the Diagnoses (ICD-10) card in the client profile sidebar. Add one by searching the code or the name (F41.1 or "anxiety"), mark one as primary, and save. They are encrypted at rest, copied into a new treatment plan, printed on superbills with pointer letters A, B, C in the order you list them, and included in chart exports.
  1 min
• Notes due and co-signaturesFrontDesk keeps a notes-due list — every completed visit without a signed note — on the Tasks page under Clinical, with a Write note button and a "No note needed" option for admin visits. A daily job nudges the provider once when a visit passes the practice's threshold (48 hours by default). Providers marked as associates or interns have their notes wait as "Pending cosign" until the supervisor named on their profile co-signs; supervisors get a task and a reminder every 7 days. Both signatures print on the chart export. Thresholds live on the Notes compliance card at the top of Settings → Template library.
  2 min
• Treatment plansA treatment plan lives on the client's Notes tab as a document you edit in place. Start it prefilled with the client's diagnoses, add goals with objectives and interventions, and sign it to activate it — that freezes the text and starts a review cycle (90 days by default). Send it to the client to sign in their portal by typed name, or record an in-person agreement. Each progress note carries a treatment-progress panel where you rate objectives 0–10, and the plan shows the trend. Reviews push the review date forward; overdue reviews appear on the Tasks page. Revising creates a new signed version with the old one kept.
  3 min
• Outcome measures (PHQ-9, GAD-7, PCL-5)FrontDesk includes the PHQ-9, GAD-7, and PCL-5. Send one from the client's Notes tab and they complete it by link or in their portal — no login needed for the link — or enter the answers yourself in session. Scores and severity bands are calculated on completion and trended on the Measures card; a positive answer on the PHQ-9 suicide item, or a high answer on the PCL-5 self-harm item, raises a risk flag that notifies the provider at once and stays on the Tasks page until acknowledged. A schedule (before each visit, weekly, every two weeks, monthly, every three months) sends the next questionnaire automatically, reminds the client once, and expires it after two weeks. Clients never see their scores.
  2 min
• Discharge, records release, and chart exportThe client's Records tab handles the end of care and the sharing of records. Discharge closes the treatment plan and measure schedules and marks the client discharged (reversible). A release of information is drafted with recipient, purpose, scope, and expiry, signed by the client in the portal or on paper, and then used to export the chart as a scoped PDF — which records a disclosure automatically. Disclosures made outside the app can be logged by hand, and the accounting of disclosures is available as a PDF for the client, who can also download a copy of their record from the portal. Psychotherapy notes are never exported.
  2 min