Access our Mental Health Sample Notes Library
Access these behavioral health sample notes and notes templates to see what type of clinical content should be included in each note.
- Biopsychosocial assessment
- Mental status exam
- Couples therapy notes
- Group therapy notes
- Nursing notes
- Case management notes
- Psychiatric Initial Evaluation Template
- Psychiatric Progress Note
- Psychiatry SOAP Note
- Psychiatric Discharge Summary
- Therapy Initial Assessment
- Therapy Progress Note
- Psychotherapy SOAP Note
- Group Therapy Note
- Therapy Discharge Summary
- Substance Abuse Inpatient Chart
- Substance Abuse Outpatient Chart
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Get access to our full mental health sample notes library
Initial Assessments
Create a comprehensive initial assessment with minimal typing.
- Present illness
- Chief complaint
- Symptoms
- Past psychiatric history
- Medical history
- Social history
- Developmental history
- Family history
- Biopsychosocial assessment
- Mental status exam
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 progress note templates 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.
- Med check progress notes
- Individual therapy notes
- Couples therapy notes
- Group therapy notes
- Play therapy notes
- Counseling notes
- Nursing notes
- Case management notes
Psychiatric Progress Note
Psychotherapy Note
SOAP Notes
ICANotes provides everything you need to create SOAP notes with ease and accuracy.
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 session notes templates so you can quickly create more effective SOAP notes for your patients.
BIRP Notes
ICANotes offers extensive note templates to help you take detailed BIRP notes in just minutes.
BIRP notes (Behavior, Intervention, Response, Plan) are critical for recording patient progress during their treatment.
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.
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 the time of discharge, and discharge instructions
Psychiatry Discharge Summary
Therapy Discharge Summary
More Resources on Writing Behavioral Health 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.