Ways to Save Clinical Notes When Using Note Designer

Introduction

Note Designer is an intuitive and efficient tool designed to help psychotherapists craft high-quality clinical notes with ease. While Note Designer does not store any notes or Protected Health Information (PHI), it provides a seamless way to create well-structured documentation that you, as the clinician, have full control over. This guide will walk you through how to use Note Designer effectively while securely saving your notes on various platforms.

Step 1: Writing Your Notes in Note Designer 👩🏻‍💻

1. Open the Note Designer software on your device.
2. Select the Note Type you wish to use (e.g., SOAP, BIRP, Child, Couple, etc.)
3. Use the intuitive interface to select content or to customize templates to fit your specific session and clinical needs.
4. If you wish, you may use Note Designer’s optional AI to help construct your note.
5. Once you have created your note, review it for accuracy and completeness.
6. When satisfied with your note, copy or export the note and proceed to save it externally using your preferred method.

Step 2: Saving Notes Securely 🔐

Though Note Designer does not store your clinical notes, there are many readily available options for documentation storage that are compatible with using Note Designer. We are not in a position to make recommendations about how to store your notes, but we are aware of different approaches employed by our users. Here are various options:

1. Saving Notes on a Computer 🖥

• Some users export the completed note from Note Designer as a PDF, or Copy/Paste into a text or Word document.
• They then save the file to a secure location on their computer. This could involve storing notes in encrypted folders with password protection (Windows and Mac operating systems have functions for this, or special encryption software can be found online).

Best Practice: Regularly updating security software, enabling firewalls, and backing up encrypted files to an external drive or secure cloud storage. Using strong passwords to open the computer and access files. Storing the device in a secure location. Using an “air-gapped” computer for storing notes – an air-gapped computer is one that is not connected to the internet.

2. Entering Notes into an Electronic Health Record (EHR) System 📊

• Many users subscribe to an online EHR system. They Copy or Export the completed note as a text/Word document or PDF from Note Designer.
• A note can then be uploaded or copy/pasted into the documentation section of the EHR.
• Save and lock the note as per the EHR’s security guidelines.

Important: Ensure the EHR system is HIPAA or PIPEDA compliant and follows all necessary privacy regulations. Common EHRs used by many Note Designer users include: Simple Practice, TherapyNotes, and TheraNest (these are the ones most often mentioned by our users). As always, be sure to maintain up-to-date security features and protections for any electronic devices being used to transmit notes to an EHR.

3. Saving to Google Workspace 💥

• Recently, some users have mentioned using Google Workspace. They Copy or Export a note as a text document or PDF from Note Designer.
• The note is then Pasted or Uploaded to the drive.
• Notes may be organized into encrypted folders for additional security.

Security Reminder: Ensure your Google Workspace is protected with two-factor authentication and encryption to comply with HIPAA or PIPEDA guidelines. Request a BAA from Google Workspace to further support HIPAA compliance. As always, be sure to maintain up-to-date security features and protections for all electronic devices being used to transmit notes to any storage system.

4. Saving to OneNote 📝

• Other users mention using OneNote by Microsoft. Copy or Export the completed note as a text document or PDF from Note Designer.
• While in OneNote, navigate to the preferred section or notebook.
• Paste the note into the appropriate section.
• Sync OneNote to ensure the note is appropriately backed up.

Security Tip: Use OneNote’s password protection feature to secure sensitive client information. Request a BAA from Microsoft OneNote to support your HIPAA compliance. As always, be sure to maintain up-to-date security features and protections for all electronic devices being used to transmit notes to any storage system.

Security Considerations for Electronic Storage 🕵🏻‍♂️

Regardless of where you choose to save your notes, it is crucial that clinicians familiarize themselves and comply with up-to-date privacy regulations. Here are some basic strategies:

1. Use Full-Disk Encryption – Encrypt your hard drive to prevent unauthorized access in case of theft or loss.
2. Enable Automatic Software Updates – Keep your operating system, antivirus, and security software up to date.
3. Install and Maintain Firewalls – Use strong firewalls to protect your computer from cyber threats.
4. Use Strong Passwords – Implement complex passwords and update them regularly.
5. Enable Multi-Factor Authentication (MFA) – Add an extra layer of security by requiring more than just a password for login.
6. Restrict Access – Limit access to sensitive information only to authorized personnel.
7. Regularly Backup Data – Store encrypted backups in secure, HIPAA-compliant locations.
8. Secure Wi-Fi Networks – Use WPA3 encryption and avoid public or unsecured networks.
9. Use HIPAA-compliant or PIPEDA-compliant platforms when storing notes electronically.
10. Implement Remote Wipe Capabilities – Enable features that allow you to erase data remotely in case of device theft.
11. Train Staff and Interns on Security Protocols – Ensure anyone with access to client information follows strict security guidelines.

Not Comfortable with Electronic Storage? 😲

5. Saving Printed Notes in a Filing Cabinet 🗄

• Use the Note Designer Print button to print the completed note.
• Store printed notes in file folders in a securely locked fire-proof cabinet.
• Delete the note from your computer once printed.

Security Reminder:

As always be sure to follow HIPAA and PIPEDA regulations for storing documentation. Store client records in a sturdy, locked filing cabinet that only authorized individuals can access. Place the filing cabinet in a locked office or a room with limited access to enhance security. Only authorized personnel should have access to paper records, reducing the risk of breaches. Protect records from potential disasters such as fires, floods, or leaks. Shred outdated or unnecessary notes using a HIPAA-compliant shredder before disposal. If files need to be moved, maintain a log to track their location and ensure they are returned.

Conclusion

Note Designer is an exceptional tool for creating high-quality therapy notes while ensuring you retain full control over how and where they are stored. Some clinicians prefer to print their notes and store them in a locked filing cabinet, while others find it convenient to store their notes electronically. We leave the decision about how and where to store client notes to you. Either way, Note Designer reduces the burden of clinical documentation by helping you write accurate, professional, and intelligent notes with ease.