Mental Health Record Samples

Mental health notes created in ICANotes with no typing required.

Initial Assessments

Create a comprehensive initial assessment with minimal typing.

The Initial Assessment sample in the video was created in 7 minutes. Only the words highlighted in yellow were typed.

You press hierarchical buttons to document the history of the following:

Diagnoses are made using drop-down menus organized in accordance with ICD-10.

For prescribing clinicians, 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.

For non-prescribing clinicians, additional menus generate content for therapy, suicide/violence risk assessment, level of care justification, and patient instructions.

Progress Notes

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

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.

SOAP Notes

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.

More Resources on Mental Health SOAP Notes

The video demonstrates how to create a psychiatric progress note in less than two minutes.

The following video demonstrates how to create a psychotherapy note in less than three minutes.

BIRP Notes

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.
More Resources on BIRP Notes

Treatment Plans

Create a comprehensive 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 video shows how to create a collaborative treatment plan that may be individually e-signed by each participating clinician.

This video demonstrates how to create a treatment plan.

Discharge Summaries

This module makes creating a discharge summary quick and easy.

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

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

Write Better Behavioral Health Notes with ICANotes

Save time and maximize your reimbursement rates on psychiatry and therapy notes.

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.