Provider Note Templates

Modern Health’s Provider Note Templates are designed to make your work easier—from reducing paperwork to keeping your clinical notes organized and secure in one location. Our standardized templates not only save you time, but also support smooth clinical transitions and consistent quality of care. These tools will allow you to focus less on administrative tasks and more on supporting your members.

Note Types and When to Use Them:

1. Initial Evaluation Notes:
   Used during first sessions to assess a member's clinical history, perform mental status exams, document diagnostic impressions, and inform treatment planning. A structured template ensures all key data is captured.

   You are not required to fill in all fields of the Initial Evaluation Note. Providers should use their best clinical judgement to determine which ones are clinically appropriate in a therapy setting and therefore should be completed.

2. Progress Notes:
   Taken during or after subsequent sessions, track a member’s status and care using the Subjective, Objective, Assessment, and Plan (SOAP) format.
   • Please note that Psychotherapy notes should never be documented within Modern Health's EMR.
   • Modern Health defines a psychotherapy note as containing the therapist's personal and subjective impressions, observations, and hypotheses about a session, which are separate from factual, objective progress notes.  Essentially, they are a therapist's personal reflections on a session.
3. Chart Notes:
   Used for interactions that are not tied to scheduled sessions—such as ad hoc phone calls, care coordination, or significant member communication outside a session.

Step-By-Step Guide: 

All documentation is managed through the Provider Dashboard, under the member’s profile.  

Document Initial Evaluations:

• Review Intake forms responses, visible in the member’s profile before or during the session.

• Choose the Initial evaluation note template and click ‘Create note’.

• Complete the standardized Initial Evaluation Note, ensuring you address all prompted fields.
• During the Initial Evaluation, you can conveniently refer to the member's Intake Form by clicking the ‘View Docs’ and selecting the desired form.

Documenting Progress Notes:

• Choose the Progress Note template.
• Link the note to the appropriate session.

• Complete all relevant structured fields for Subjective, Objective, Assessment, and Plan.
  • Sign when finalized to lock the note.
  • Please note: While we encourage you to use our note template, if you typically do not use the SOAP note framework, please write your progress note as free text in any of the four fields. 

Creating Chart Notes:

• Use “Chart Note” for miscellaneous or ad hoc clinical events.

• Fill out the free text field, specifying the context (e.g., care coordination call) and when the interaction occurred.
• Selecting a session time is not required.
• Chart Notes also auto-captures timestamps.

Session & Chart Note Differences:

• Session Notes correlate directly to clinical appointments. 
• Chart Notes capture non-session-related events and communications.
• Psychotherapy Notes—which are strictly for a provider's personal reflections and kept separate from the EMR—should never be used within Modern Health's EMR, as all documentation is intended for clinical hand-off and audit readiness under HIPAA. 
  • Modern Health defines a psychotherapy note as containing the therapist's personal and subjective impressions, observations, and hypotheses about a session, which are separate from factual, objective progress notes.  Essentially, they are a therapist's personal reflections on a session.

Key details for all note templates:

• All notes auto-save every 60 seconds.
• Signing a note locks it for editing.
• Once a note has been locked, use “Chart Note” for miscellaneous or ad hoc clinical events. 
• Unsigned notes can be discarded and restarted, with discarded drafts preserved for audit as needed.

Privacy: Access and Member Relationships

• Provider & Member Matching:
  • While matched, providers can view all available notes associated with  a member’s chart (including those authored by previous providers).

• Note Access After Unmatching:
  • If an unmatched provider needs access for a valid clinical reason, please contact the Provider Support Team ([e-mail]) for guidance.