All of our records are electronic and are stored in Janeapp. Your clinical notes must follow the requirements of your college (I.e. CRPO). Clinical notes are legal documents and must be treated as such. Your notes must be completed within 48 hours of the completed session. In exceptional circumstances you may need to delay note-taking, if you do need to delay completing a clinical note, please contact the site owner, Brittany Barratt.

Clinical notes are legal documents that may be subpoenaed in rare circumstances by a judge. Therefore, all notes must be professionally and clearly written without grammatical errors, written in a concise manner, and must not contain any diagnostic language. Legally therapists are not able to provide a clinical diagnosis so it is important that your language reflects such. Clinical notes must be attached to an appointment date. For information how to do this, please see charting basics training provided earlier in this operation manual. Any correspondence that is clinical in nature (I.e., an emailed update from a client, or a completed worksheet) need to be included in the clients chart file. To do so, simply add a blank note titled “email correspondence” and attach  or copy-paste any exterior correspondence. 

To uphold PHIPA requirements and duties of the HIC, regular audits will be conducted to ensure chart note completion.

*For documents that you’d like to send to clients, please use janes “file” feature, which allows you to securely send a client a file (ie. worksheet), which they can access through their Jane portal