Clinical Documents

Initial Assessments

This module enables you to create a comprehensive initial assessment with no typing. You press hierarchical buttons to document the history of present illness, chief complaint, symptoms, past psychiatric history, medical history, social history, developmental history, family history, and mental status exam. Diagnoses are made with all five axes using drop-down menus organized in accordance with DSM IV. The initial assessment includes an optional medication order and patient recommendations. You press a single button and ICANotes self codes based on the content of your assessment. The following Initial Assessment sample was created in 8 minutes with only one sentence typed by the clinician.
 

Progress Notes

Four types of progress notes can be generated in ICANotes: a Psych Progress Note, a Group Therapy Note, a Counseling Note, and a Nursing Note. The Psych Progress Note module contains buttons for use by inpatient clinicians. Each note is designed to capture the patient’s interval history and mental status exam as well as the clinician’s diagnosis and recommendations. The following Progress Note sample was created in 3 minutes with one sentence typed by the clinician (“He says, “I hate my life.”)
 

Treatment Plans

This module supports 19 common psychiatric problems. ICANotes offers a selection of short-term goals, long-term objectives, strengths/assets, and other details required by treatment plans. Interventions for each member of the treatment team are available. There are also separate social work and medical/nursing problems with long- and short-term goals and interventions. The following Treatment Plan sample was created in 7 minutes with no typing.

Discharge Summaries

This module makes creating a discharge summary quick and easy. It prints a cover page, your initial psychiatric assessment, all progress notes in a compressed format, and a final page which includes risk factors, final diagnosis, condition at time of discharge, and your instructions to the patient. An optional page for you to dictate or type additional information is also available. The following Discharge Summary sample was created in 7 minutes with no typing.

I used to spend two or more hours per day on clinical documentation. Since switching to ICANotes, I typically spend less than 30 minutes per day on documentation, which frees me to generate at least two additional billable sessions per day.

Carl L. Stephens, LCPC,
Myersville, MD