Therapy House

Note Taking

Ensure you are familiar with APS Code of Conduct and APS Guidelines on Record Keeping

When to Write

  • After each session (including intake, assessment, or feedback session)
  • After a phone discussion that has any therapeutic content (with a client or client contact such as a teacher)
  • After an incident

Where to Write

Notes are completed on client profile and linked to the relevant appointment attended

Power Diary has a number of templates that can be utilised and allow for attachments to be added:

  • Basic Case Notes
  • Case Formulation
  • Case Summary
  • Child Summary
  • Clinical Notes
  • Diary Link
  • Group Therapy
  • Incident Report
  • Informed Consent
  • Meeting with Teachers
  • MSE
  • Risk Assessment
  • Suicide/Self Harm Safety Plan
  • Supervision

How to complete notes

  1. Go to your diary and double click on your client
  2. Click Records in the menu and then Notes
  3. Click Create New and select a template *if you’d like to duplicate and edit your last note, you can click the double page duplication icon
  4. Fill out all relevant information
  5. Click the attachment link at the bottom of the page to attach any resources or notability files
  6. Click ‘Save and Complete’ to save the note
  7. Return to your diary, single click on your client and next to Flag, use the drop-down box to select Notes Complete
  8. Click Save and your client should show in Green on your calendar to signify completed

Note: Do not complete steps 7 and 8 if you have completed an intake – you want to be able to look back in your calendar and see which appointments were intakes.

Note: You can copy/clone a previous note by clicking the two square icon. This will help you retain the information you have already entered such as important names hobbies etc, and only modify as appropriate.