Psychiatry Sample Notes

Sample psychiatric progress notes created in ICANotes with no typing required.

Initial Assessments

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, biopsychosocial assessment 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

These notes can be used in both outpatient and inpatient settings.

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.

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.

Treatment Plans

Create a comprehensive psychiatric treatment plan with minimal typing.

The Treatment Plan 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.

The following Discharge Summary sample was created in 8 minutes with no typing.

Intuitive, Accessible, Time-Saving

ICANotes - the only EHR software that actually thinks like a clinician.