Mental Health Record Samples
Mental Health Progress Notes Created in ICANotes with no Typing Required.
Psychiatry Note Samples
Easily create detailed assessments, progress notes, treatment plans, and discharge summaries.
Using hierarchical buttons, you can take a comprehensive initial psychiatric assessment in just minutes. Thanks to our robust templates and customization, you can easily document the following items and stay in accordance with ICD-10:
- History of present illness
- Chief complaint
- Symptoms
- Psychiatric history
- Medical history
- Social history
- Developmental history
- Family history
- Mental status exam
With just a few clicks of a button, you can create detailed psychiatric progress notes in under two minutes. Using ICANotes Behavioral Health EHR software, you'll be able to easily update your patient's progress and keep track of their interval history, status exams, clinician diagnoses, and recommendations.
- Med check progress notes
- Group therapy notes
- Counseling notes
- Nursing notes
- Case management notes
ICANotes Behavioral Health EHR software is equipped with treatment plan modules for common mental health problems, nursing problems, social problems. We also offer a module specifically tailored to chemical dependencies and have included a variety of short-term and long-term goals for each of these problems. View our treatment plan sample to learn more.
Discharge summaries are a critical part of the discharge planning process. Whether the patient is transferring to a new clinician or completing their treatment plan, psychiatric discharge summaries provide detailed records of the patient's mental health history, status exams, diagnosis, recommendations, medication orders, and more. Our discharge summaries include the following items:
- Cover page with initial psychiatric assessment
- All progress notes in a compressed format (optional)
- Final page with patient risk factors, final diagnosis, condition at time of discharge, and discharge instructions
Therapy Note Samples
Create comprehensive psychotherapy notes just three minutes with ICANotes Behavioral Health EHR.
Improve efficiency without sacrificing the quality of your mental health progress notes. ICANotes offers clinically robust templates for:
- History of present illness
- Clinical status
- Symptoms
- Behavior
- Verbal content
- Therapeutic focus & interventions
- Private notes
- Rating scale scores
- Mental status exams
- Level of care justification
- Links to treatment plans
- Suicide & violence risk assessments
- Clinician's diagnosis
- Risk factors
- Medical history
- Clinician's instructions & recommendations
The SOAP note (Subjective, Objective, Assessment, Plan) is an important part of any patient's chart as it provides clear and concise information on a patient's condition that can be easily interpreted for faster treatment. ICANotes offers comprehensive templates so you can quickly create more effective SOAP notes for your patients.
BIRP notes (Behavior, Intervention, Response, Plan) are critical for recording patient progress during their treatment. ICANotes offers extensive templates to help you take detailed BIRP notes in just minutes.
What should BIRP Notes Include?
As a general rule, BIRP notes should include the following items:
- Behavior: counselor observations as well as statements and direct quotes from the patient.
- Intervention: the methods used by the counselor to address the patient's goals, objectives, statements, and observations.
- Response: the patient's response to the methods of intervention and any progress the patient has made toward treatment plan goals and objectives.
- Plan: any revisions to the current treatment plan and course of action for the patient including the clinician's next steps and the next session date.
Valerie Barfield
APRN, GNP-BC, Sage Lifecare, Memphis, TN
"ICANotes creates a narrative note that is readable and thorough. I get lots of compliments on my documentation and I feel more confident in my coding.”
Intuitive, Accessible, Time-Saving
ICANotes - the only EHR software that actually thinks like a clinician.