A Guide to Using Progress Notes

Edited

The Progress Notes feature allows staff to record notes regarding a specific Service User or the community as a whole.

Many clients use this feature to record daily diaries or summaries for each Service User.

Please watch this video, which covers:

  • How to create a new Progress Note

  • How to flag a Progress Note for Management

  • How to view Progress Notes for a specific Service User

  • How to edit or delete a Progress Note

  • Unique identifiers for Progress Notes

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How to Edit Progress Notes Settings

Those will the appropriate permission level will be able to view and make changes to Progress Note Settings.

To access settings, click on the cog icon.

Make changes by switching the toggle to enable or disable feature settings such as

  • The ability to tag a service user in a note

  • The ability to flag a note for the Manager Dashboard

  • The ability to see who has read the Progress Note

  • The ability to see a timestamp if the Progress Note was edited or changed

  • The ability to tag notes with custom note tags

  • The ability to require a time entered into a note

  • The ability to prefill date and time to the current date and time

  • The ability to allow future dates and times to be entered into the date and time selection

  • The ability to require service users/residents to be tagged in order to save a note

This is also where you can change the terminology of Progress Notes to something of your choosing.

How to Add Tags to Progress Notes

Note Type Tags

Create tags to be used with Progress Notes. (Example tags: codes, communication types, levels of support, etc.)

  • Add tags you would use by clicking the + sign.

  • Give the tag a title.

  • Click the green disc icon to save it.

  • Change the color of the tag by clicking on the color rectangle next to the tag title.

Once saved, you will see tags appear in a drop-down menu the next time you go to create a Progress Note. Multiple tags may be selected.

How to Create and Use Progress Note Templates

StoriiCare allows staff to streamline documentation by applying pre-created Progress Note Templates directly within a participant note. Templates help ensure consistency and save time for commonly used formats. Ensure that 'Templates' is enabled in Progress Notes Settings in order to access the below.

How to Apply a Template to a Progress Note

  1. Open or start a new Progress Note for a participant.

  2. Select the template icon at the top left of the note editor.

  3. Choose Apply a template from the menu.

  4. Search for or select the template you want to use, such as ADL and Participation, Health Monitoring and Behavior Tracking, or Strengths Based Social Engagement.

  5. The template fields will auto-fill into the note editor. You can then edit or add any additional information as needed.

  6. When you finish documenting, click Save.

Administrators can manage templates from the Progress Notes Settings area.

  1. Go to Settings

  2. Navigate to the 'Templates' area at the bottom of Settings

  3. Create a new template with the plus icon or edit an existing one using the 'Pencil' icon

  4. Add your text, headings, or prompts that should appear whenever staff apply the template

  5. Save your changes

Once created, templates become available for all staff to use when writing Progress Notes.