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How to Write a Psychiatric Service Note for an Unscheduled Service 

  1. 1. Open the client’s chart. 

  1. a. Click the Client Search icon. 

  1. b. Type in the client’s name (last name, first). Note: You do not need to enter the entire name for the search to work. 

  1. c. Select the client from the search results. 

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  1. 2. Open a new service note 

  1. a. Click on the Search icon. 

  1. b. Type in “services/notes” in the search bar. 

  1. c. Select “Services/Notes (Client)” from the search results.  

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  1. 3. This takes you to the client’s service list page. Click the New icon. 

  1. 4. This takes you to the service note screen. Enter the service information. Required fields are marked with a red asterisk (*).  

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  1. Follow the steps outlined above in How to Write a Psychiatric Service Note for a Scheduled Service. 

 

Note: You can also create a new service via your Staff Calendar, or by adding this document to your favorites. See the Clinical Documentation User Guide for more information.