Therapy Sample Notes

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

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.

Intuitive, Accessible, Time-Saving

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