Therapy Sample Notes

Sample mental health progress notes created in ICANotes with no typing required.

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.

Initial Assessments

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.

Progress Notes

Many types of progress notes can be generated in ICANotes:

Individual Therapy, Couples Therapy, Group Therapy, Case Management, Play Therapy, and more.

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.

Treatment Plans

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.

Discharge Summaries

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.

Cures Act Compliance

Beginning April 5, 2021, all medical practices will need to comply with open-notes regulations put in place by the 21st Century Cures Act passed in 2016. This regulation requires practices to provide patients with online access to their notes, records and treatment plans. While some psychotherapy notes may be exempt, the majority of patient notes will need to be made accessible.

These new Cures Act regulations will put additional pressure on clinicians to ensure their notes are comprehensive and clear to patients who may view them. Fortunately, with ICANotes, you won't have to do any additional work. Before the April regulations go into effect, ICANotes will be fully 21st Century Cures Act compliant.

Efficient Note-Writing With ICANotes

For more than 20 years, ICANotes has been working to provide complete practice management and EHR software to therapists, psychiatrists, counselors and other behavioral health professionals. We have tailored our software and services to meet your practice's unique needs.

ICANotes' software is specially developed to help you take comprehensive, efficient and effective notes about your clients' sessions. All notes are Cures Act- and HIPAA-compliant.

Our pricing system is based on the size of your practice and the services you wish to employ, so you will only pay for what you need. Additionally, we have no annual contracts, and since fees are paid on a monthly basis, you aren't locked into any long-term commitments.

When you choose to integrate ICANotes into your practice, you and your staff receive unlimited one-on-one web-based training sessions and expert support to troubleshoot with you and ensure everything runs smoothly.

Interested in trying out ICANotes? We offer a free trial so you can see firsthand how ICANotes can benefit your practice.

To request more information, you can contact us online or give us a call at 866-847-3590.

Intuitive, Accessible, Time-Saving

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