Creating Notes in the EMR

Applies to:

• Providers, Org Admins, Supervisors and Support Staff using the Pathfinder EMR

Overview:

Notes support coordinated care by allowing:

• Counselors to stay informed on client updates
• Supervisors to monitor clinical progress
• Admin staff to understand context when interacting with clients
• Care teams to tailor conversations and services based on recent developments

Consistent note-taking improves communication across the care team and leads to better outcomes for your members.

Common Issues:

• Staff unsure where to add notes
• Confusion about note visibility settings
• Care team members not aware of internal communication tools
• Inconsistent documentation between providers

Two Ways to Add a Note

The EMR gives you two places to add notes depending on what you're documenting:

Both methods create an internal note on the client's profile — the difference is simply where the note lives and who typically uses it.

Adding a Note from Clinical Care Tab

1. Navigate to the Client Profile page.
2. Click on the Clinical Care tab.
3. Select Add Note.
4. A pop-up box will appear displaying the client’s name.
5. Enter your note (e.g., “Had a rough meeting with probation.”).
6. Review the visibility settings:
   1. Notes are visible to Admins and Supervisors by default.
   2. If the client has multiple peers assigned, you'll see a peer visibility toggle:
      1. Toggle ON to allow all assigned peers to view the note.
      2. Toggle OFF to keep the note limited to Admins and Supervisors.

7. Click Confirm to save.

   
   

Adding a Note from the Notes Tab

This method is used by Admins to log billing details or other administrative information about a client.

1. Navigate to the Client Profile page.
2. Click the Notes tab (located near Clinical Care).
3. Select Add Note.
4. Enter the note and confirm visibility settings.

5. Click Confirm.

   
   

Troubleshooting 

Not sure which tab to use? Use the Clinical Care tab for anything care-related, and the Notes tab for billing or administrative details.

Don't see the peer visibility toggle? This option only appears when a client has multiple peers assigned to them. If you only see the default visibility settings, the client likely has just one peer assigned.

Can't add a note? Make sure you have the appropriate role permissions — note creation requires a Provider or Admin role. If you believe your permissions are incorrect, reach out to your Org Admin.

Unsure who can see your note? Check the visibility settings before saving. By default, notes are visible to Admins and Supervisors only. Use the peer toggle if you want to extend visibility to assigned peers.

Team members missing important updates? Make sure your team is using notes consistently — and that peer visibility is toggled on when broader team awareness is needed.

Inconsistent documentation across providers? Consider establishing a team standard for how and when notes should be added to keep everyone aligned.