As a behavioral health clinician, you know that writing comprehensive and concise notes is an essential aspect of providing patient care. You see a lot of clients, and they see other clinicians within and outside of your practice, so it's important to have clear, easily understood notes from each session to ensure your patients receive the best care possible. However, note-writing can be a time-consuming and labor-intensive process, and time spent trying to decipher handwriting or typos is better spent elsewhere.
Using note-writing software like ICANotes can streamline your documentation process by making your notes fast, concise, accurate and consistent. Our button-driven template format lets you write notes with minimal typing, which helps prevent inaccuracies and allows you to take better notes in a fraction of the time required by other methods.
Our program autosaves with every click or keystroke, so you can be sure your notes are saved even if you accidentally navigate away. Additionally, our integrated note-writing software keeps everything in one place, making it easy for clinicians to refer to previous notes, treatment plans and diagnoses.
Below, you will find sample therapy notes created with our software and detailed information about how these notes were created.
Create a comprehensive initial assessment with minimal typing.
Use our content templates to document in narrative form the history of present illness, chief complaint, symptoms, past mental health 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.
Additional menus generate content for therapy, suicide/violence risk assessment, level of care justification, and patient instructions.
Many types of progress notes can be generated in ICANotes:
Each note captures 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.
The treatment plan module includes templated content for 32 common mental health problems as well as 43 nursing problems and 18 social problems.
ICANotes offers a comprehensive selection of long-term and short-term goals for each problem as well as intervention content for each goal.
We also have a treatment planning module specific to chemical dependency.
This video demonstrates how to create a treatment plan.
This module makes creating a discharge summary quick and easy.
It prints a cover page with your initial 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.
Intuitive, Accessible, Time-Saving
ICANotes - the only EHR software that actually thinks like a clinician.