Mental Health Records

Initial Assessments

This module enables you to create a comprehensive initial assessment with minimal 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 ICD-10. The initial assessment includes fields for medication orders and patient recommendations. You press a single button and ICANotes provides an E/M code based on the content and complexity of your assessment. The following Initial Assessment sample was created in 7 minutes. Only the words highlighted in yellow were typed.

Video DemoVideo Demo       Assessment Sample


Progress Notes

Many types of progress notes can be generated in ICANotes: Med Check Progress Notes, Group Therapy Notes, Counseling Notes, Nursing Notes, Case Management Notes, and more. These notes can be used in both outpatient and inpatient settings. 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 video demonstrates how to create a psychiatric progress note in less than two minutes.

Substance Abuse Group Therapy Note

Psychotherapy Note

Inpatient Nursing Note

Treatment Plans

This module supports 31 common mental health problems as well as 43 nursing problems and 18 social problems. We also have a treatment planning module specific to chemical dependency. 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 video demonstrates how to create a collaborative treatment plan that may be individually e-signed by each participating clinician.

Sample Treatment Plan: Inpatient

Sample Treatment Plan: Outpatient

Discharge Summaries

This module makes creating a discharge summary quick and easy. It prints a cover page with your initial psychiatric assessment, all progress notes in a compressed format (optional), and a final page which includes risk factors, final diagnosis, condition at time of discharge, and discharge instructions for your patient. An optional page for you to dictate or type additional information is also available. The following Discharge Summary sample was created in 8 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

  • Moving from paper to electronic records in behavioral health
  • Mental Health Group Therapy Notes
  • Patient Portal for Behavioral Health