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.

ICANotes Tablet-compatible behavioral health ehr software

Psychiatric Evaluations & Initial Assessments

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

Learn More About Creating Progress Notes

Psychiatric Treatment Plans

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.

Check Out Our Guide to Creating Mental Health Treatment Plans

Psychiatric Discharge Summaries

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.

View Therapy Note Samples

Psychotherapy Note Templates

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

Mental Health SOAP Notes

Behavioral Intervention, Response, Plan (BIRP) Progress 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.

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.”

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