[Navigation] Global Search > Utilities > Form Builder > Progress Note
[Accordion] Overview
Custom Progress Note Forms provide a refined and purposeful way to capture the ongoing narrative of a patient’s care. Designed to document observations, interventions, and meaningful clinical updates, these forms are accessed directly within an Appointment record, ensuring each entry is accurately linked to the appropriate encounter.
By supporting clear, structured documentation for every visit, therapy session, or treatment interaction, Progress Note Forms help clinicians maintain continuity, clarity, and clinical insight throughout the patient’s care journey.
Who uses Custom Progress Note Forms:
- Clinicians and therapists use Custom Progress Note Forms to document therapy sessions, follow-up visits, and clinical encounters
- Behavioral Health Professionals record observations, interventions, and patient responses
- Authorized Clinical Staff maintain standardized progress documentation across patient visits
Purpose of using Custom Progress Note Forms:
- Document session observations, therapeutic interventions, and clinical status updates
- Record encounter details, including dates, times, focus areas, and completed interventions
- Capture structured assessments, goals addressed, and patient responses
- Electronically sign and finalize progress notes as part of the clinical workflow
[Permissions] The staff member must have Full access to Form Builder [Staff > Staff Info > System Permissions > Form Builder] to design Progress Notes
[Accordion] Getting Started
To help you get started, we'll use a sample Progress Note as a practical example for building a form in the Form Builder. The this Progress Note is designed to capture essential visit-level information in a clear, structured, and repeatable format.
This example demonstrates how key fields, such as visit details, observations, interventions, and outcomes, are organized to promote consistency. The straightforward layout helps clinicians document visits efficiently and accurately.
To build this form, we'll use a combination of commonly used form controls, including:
- Memo fields to capture narrative clinical observations
- Date and Time Pickers to record when the service was provided
- Selection controls, such as List Boxes and Checkboxes, to document focus areas and interventions performed
- Repeating Lists to capture multiple observations, goals, and patient responses within a single encounter
- A Digital Signature to review, finalize, and authenticate the note
Additionally, specific control properties, such as Field Labels, Fonts, Required for Save settings, and Margins, have been configured and adjusted as needed to meet documentation standards and compliance requirements.
Progress Note Form Category: To create a Custom Form Progress Note, navigate to Form Builder and select the Progress Note Form category.
- [[img:edit]] Click/Tap to create or edit a Progress Note Form
Choosing a form design:
[[img:Playlist_Add >>lbl:Create New Form]] Click/Tap to design and create a new custom progress note
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Actions:
- Edit Design: [[img:edit]] Click/Tap the edit icon to modify an existing custom progress note
- [[img:more_vert]] Three-dot Menu: Click/Tap for additional options related to a specific form
- Clone Form: Click/Tap to create a duplicate of the selected form
- Delete Form: Click/Tap to permanently remove the selected form
- Distribute Form: Adds the form to the Create Progress Note button on the Patient Contact/Appointment module
- Generate AI Prompts: Click/Tap to automatically generate default AI prompts based on field labels for all AI-capable fields that don't currently have an AI prompt and don't rely on formula-based calculation values
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Quick Filter Tags:
- Enabled: Select to view active Progress Notes
- Disabled: Select to view inactive Progress Note
[Q] Designing a new Custom Progress Note:
[A] Create the sample Progress Note form by selecting the required controls from the left-hand side of the Form Builder. Drop these controls onto the middle section, which serves as the form canvas. Use the right-hand properties panel to configure each field’s settings, such as labels, required fields, and display settings.
To create a custom Progress Note for documenting a patient encounter or therapy session, you may include the following fields:
- Memo Without Format: Used to capture information like observation notes, where no special formatting is required. The Width Percentage and Margin Top properties have been adjusted to improve visual alignment, readability, and spacing within the form layout, making the field easier to locate and use during data entry.
- Date Picker: Used to record the date of the clinical interaction or service provided. This field has been marked as required to ensure the date of the observation or session is accurately captured, supporting proper tracking and audit readiness.
- Time Picker: Used to capture the start and end times of the session. The Start Time has been set to Required (*) to record when the session or interaction began, helping establish clear timelines. The End Time has also been set to Required (*) to record when the session or interaction concluded, enabling accurate duration calculation and ensuring completeness of time-based records.
- List Box: Used to select one or more focus areas addressed during the session (for example: mood, behavior, coping skills, medication adherence).
- Checkbox: Used to indicate whether specific interventions were performed (such as counseling provided, safety plan reviewed, or caregiver involved).
- Repeating List: Used to document multiple interventions or observations within the same Progress Note, allowing entries to be added dynamically.
- Digital Signature: Used to electronically sign and finalize the Progress Note after documentation is complete. The signature field has been set to Required (*) to confirm authorship and accountability, ensuring that the progress note is formally validated by the individual who completed it.
[Note] When creating a Progress Note, you are not limited to these fields, and can select and add other fields based on your specific requirements.
Follow the steps to create your Progress Note:
- Navigate to Utilities > Form Builder
- Choose a Form Category (e.g., Progress Note)
- Click/Tap [[img:playlist_add >> lbl:Create New Form]]
- Enter the Form Details: Form Name, Form Description, General AI Prompts (add general instructions for AI to follow)
- Add fields such as:
- Observation notes
- Therapy interventions
- Status updates or vital signs
- Checkboxes for completed tasks
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Save and Distribute the form.
Once distributed, the form becomes available as an option within the Patient Contact/Appointment record.
Working with Progress Note Forms
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Open the Patient Contact record
- Choose a new Progress Note for the visit or session from the left pane
- Review previous Progress Notes for context and continuity
- Use structured fields to maintain consistency in documentation across clinicians and visits
[Accordion] Best Practices
[Q] Keep it structured and simple
[A] Use consistent sections (e.g., Observations, Interventions, Outcomes), so clinicians know exactly where to enter information.
[Q] Use the right control for the data
[A] Choose dropdowns, checkboxes, or radio buttons for standardized data, and text areas for narrative clinical notes.
[Q] Limit required fields
[A]Mark only the essential fields as required to avoid slowing down documentation while still capturing critical information.
[Q] Use clear, clinician-friendly labels
[A] Field labels should be concise and familiar to clinical staff to reduce confusion and data entry errors.
[Q] Maintain consistency across notes
[A] Reuse field names, layouts, and formats across Progress Notes to support easy review and reporting.
[Q] Optimize for speed
[A] Place commonly used fields at the top and group related fields together to minimize scrolling and clicks.
[Q] Allow flexibility for clinical judgment
[A] Include optional free-text fields to allow clinicians to document unique or complex situations.
[Q] Test before rollout
[A] Preview and complete the form as an end user to ensure the flow makes sense and all required data can be entered smoothly.
[Q] Review and refine regularly
[A] Gather clinician feedback and update the form as workflows or documentation needs evolve.
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