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 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.

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 psychotherapy note in less than three minutes.

Treatment Plans

This module supports 32 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 comprehensive selection of long-term and short-term goals for each problem. Intervention content for each member of the treatment team is also available. The following video demonstrates how to create a collaborative treatment plan that may be individually e-signed by each participating clinician.

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