Primary Care Note

Primary Care Note

Overview

ICANotes+ enables you to create a Primary Care Note. Like other notes, you can use shrubs to capture content efficiently. You can also document service codes, diagnosis codes, prescribe medications, and record risk factors, medical history, and more. Each of these features is explained in detail in this knowledge base article.

After completing the note, you can compile it. Once compiled, the note can be electronically signed, printed, or downloaded.

Info
The Primary Care Note feature is currently available exclusively for prescribers.

Accessing Primary Care Note

To create a Primary Care Note:

  1. Go to the Chart Room.

  2. Select a client.

  3. Open the Chart Face tab.

  4. Click the Primary Care Note button.




Creating Shrub Content for Primary Care

Use the Primary Care buttons in the left pane to create shrub content.

  • Clicking a button opens a slide-out panel where you can record the relevant symptoms or information.

  • Once saved, the content is added to the shrub.

The following buttons are available in the Primary Care note:

  1. Client Has Symptoms of
  2. Suicide / Violence Risk
  3. Physical Exam
  4. Annual Wellness
  5. OBGYN
  6. Prostate Exam
  7. Immunizations & Screening
  8. See Detailed ROS
  9. Tobacco Use
  10. Rating Scales
  11. Mental Status Exam
  12. Appearance
  13. Vital Signs




Select symtoms on the slide-out and click Save.



Prescribing Medications

The Primary Care Note allows you to prescribe medications and record client allergies. The Medication box is located in the top-right corner of the note.

For more details, see: 
  1. How to prescribe a medication
  2. How to add an allergy
  3. eRx Feature Knowledge Base articles




Recording Diagnosis Codes

In the Primary Care Note, you can record diagnosis codes (ICD-10). The Diagnosis box is located below the Medication box. In the Diagnosis box, you’ll see the option “Include Diagnosis in the note?” Select No if you don’t want the diagnosis code to appear in the compiled note. Providers can also set a default preference to automatically include or exclude diagnosis codes in the compiled note from their personal preferences.




Recording Service Code

The Primary Care Note allows you to record service codes. The Service Codes box appears beneath the Diagnosis box. In the Service Codes box, you’ll see the option “Include Service Codes in the note?” Select No if you don’t want the service code to appear in the compiled note. Providers can also set a default preference to automatically include or exclude service codes in the compiled note from their personal preferences.

For more information, see How to Set Up Practice Service Codes.



Recording Risk Factors and Medical History

You can record client risk factors and medical history in the Primary Care Note. These details appear in all notes (past and future). In the respective boxes, you will see the questions “Include Risk Factors in the note?” and “Include Med History in the note?” Select No if you do not want this information to appear in the compiled note. Providers can also set a default preference to automatically include or exclude risk factors and medical history in the compiled note from their personal preferences.



Creating a Lab Order

From the Primary Care Note, you can place either electronic or manual lab orders. Use the Create Lab Order button to begin.

For more details, see:

  1. Electronic Lab Orders and Results
  2. Manual Lab Orders and Results



Recording Time Spent with the Client

Use the Time Spent button to record the duration of a client session. Clicking this button opens a modal where you can enter the session’s start and end times. The recorded times appear in the compiled note.


  1. Start: Enter the session start time.
  2. End: Enter the session end time.
Alert
Entering a start time automatically sets the note time to match.



Linking Note to a Treatment Plan

You can link a primary care note to an existing treatment plan for a client. The Link to Treatment Plan option lets you select the appropriate plan—either general or chemical dependency. When you link the note, the content is added to the Instructions and Recommendations section of the note. You can also copy this content into a chart flag message if needed.


Clicking Link to Treatment Plan opens a screen where you can choose the desired options from the dropdown list. The linked plan is then displayed in the right pane. 
 


Once linked, the treatment plan appears in the Instructions and Recommendations section of the note.

To copy the linked treatment plan into a chart flag, select Copy to Chart Flag.

 

The chart flag message remains accessible at any time from the client ribbon by selecting the flag icon at the top of the screen.


Recording Course During Treatment

The Course During Treatment field is used to document details about the client’s course of treatment. Information entered here is for reference only and does not appear in the compiled note.



Selecting the Course During Treatment button opens a screen where you can enter your notes. These entries remain internal and will not display in the compiled note.

To add a new entry for today’s date, select Enter New Note Date and Divider. This separates your latest note from previous entries for easier tracking.



A green check mark appears next to the Course During Treatment button to show that the field contains content.



Entering Private Notes

The Private Notes field is used to record information intended for the clinician’s reference only.

Content entered here:

  • Does not appear on compiled or printed notes.

  • Is not considered part of the official client record.

  • May still be accessed if requested through a legal subpoena.



Selecting the Private Notes button opens a screen where you can enter your notes.

To add a new entry for today’s date, select Enter New Note Date and Divider. This separates your most recent note from older entries.


A green check mark appears next to the Private Notes button to show that the field contains content.


Recording Follow-up Details

Use the Follow-Up dropdown to select the desired timeframe for scheduling a follow-up visit for the client.


The dropdown offers several options, such as One Month or Earlier, One Week or Earlier, and others. Select the appropriate option for the follow-up. The chosen follow-up information will appear in the compiled note.


Creating Custom Buttons

In addition to the existing shrub, you can create custom buttons to include in your shrub content. Each custom button can have up to three variations. When you click the Create Primary Care button, the system randomly selects one of the variations for use in the note.



Clicking the Create Primary Care button opens the setup screen.
  1. Step 1: Enter the button name as it should appear on the note for selection.
  2. Step 2: Enter up to three variations for the button; the system will randomly use one of them when the button is clicked.



You can also create custom buttons for instructions, which will appear in the Instructions and Recommendations section.


Compiling Primary Care Note

After entering all details in the primary care note, click the Compile and Preview button at the bottom right.


Once compiled, the note appears as shown below. From this view, you can:

  1. Download the note
  2. Print the note
  3. Copy note content
  4. Electronically sign the note
  5. Navigate to the chart face
  6. Access work areas
  7. Generate an invoice
  8. Create a Discharge Summary
  9. Create a Clinical Summary



FAQs 

You can find the Frequently Asked Questions (FAQs) on our Knowledge Base page.


Click here for quick access to the FAQs.

Need Help?

For further assistance, contact:
📞 Phone: 443-203-5857
📱 Text: 866-301-0085
📧 Email: ticket@icanotes.com
💬 Chat: https://app.icanotes.com

Proprietary Notice Information: This article is provided for informational purposes only, and the information herein is subject to change without notice. While every effort has been made to ensure that the information contained within this article is accurate, ICANotes cannot and does not accept any type of liability for errors in, or omissions arising from the use of this information.

    • Related Articles

    • How to Document an Episode of Care

      The Chart Face section displays information relating to the client’s current episode of care. Each created chart contains a new episode of care. Click the pencil icon to the right of the screen to make changes to the current episode of care. The Edit ...

    • Readability Enhancer: Use AI to Improve Your Note Content

      Overview The Readability Enhancer feature in ICANotes+ uses artificial intelligence (AI) to help improve the clarity and professionalism of your note content. You can refine the entire note or enhance specific sections based on your needs. ⚠️ ...

    • Practice Note Settings

      Overview This guide covers the workflow for practice owners customizing note settings at the group level in ICANotes. Navigate to Note Settings From the left-hand navigation menu, go to Settings Click into the Note Settings section. Here you can ...

    • Configure Default Note Settings

      Overview On the client’s chart face, multiple note types are available, such as Progress Note, SOAP Note, and Quick Note. You can prioritize the note type you use most frequently for quicker access. For example, if you regularly create Progress ...

    • Add Same Primary Insured SSN for Multiple Clients

      Overview This knowledge base article guides you on how to create client charts for siblings or multiple clients who share the same Primary Insured party (for example, a parent or guardian). Following this process ensures that the system correctly ...