A case note is a non-billable note that is still clinically relevant. For example, if you answer some questions that the patient had over the phone. While the conversation wasn’t billable, you can document the communication in a case note.
Let's review how to create a case note.
To create a case note, navigate to the Patient Record Actions and select Case Note from the drop down menu.
Once Case Note is selected, click the play button.
Add the date, a title, and enter the note details. Select Save As Draft to complete the case note at a later time. You can forward the note to another provider or therapist assistant, preview the note to check for accuracy, or finalize the case note.Note: Case notes can only be removed while in draft mode; once finalized, it cannot be removed/deleted. The only exception is PDF Flowsheets (a permanent version is kept in the flowsheet section of the chart). You can, however, make an addendum to make changes to a case note.