You can keep clinical notes directly in Saltroad using the Clinical Notes feature.
You can create rich-text notes, with a searchable history so you can quickly find a customer's previous notes.
All notes are linked to a specific session, so your notes live alongside the relevant unit of work rather than in a separate system.
To create a new note:
Click the “+ New Note” button on the Clinical Notes page
Find the relevant customer & service the note relates to
Pick the session (eg. session 3 from a block of 6)
Type up your notes (changes are saved automatically)
Find, open and edit all notes from the main Clinical Notes page
And a few important things to highlight:
Notes can only be added to sessions not yet marked as delivered for payment
If there is an Appointment booked for a session, this date pulls through as the session date to the note, but can be changed if needed
Within a note, you can do some basic text formatting, download a PDF version or copy and paste the text to other docs as needed.
All notes are stored securely in our encrypted database and only directly accessible to you.
Saltroad requires that all therapists meet the record keeping standards set out by the HCPC. These cover keeping clear, accurate and contemporaneous records, storing them securely, and retaining them for the appropriate period.
See the HCPC guidance for full details: https://www.hcpc-uk.org/standards/meeting-our-standards/record-keeping