Mental Health Records

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

Learn More About Creating Progress 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.

Check Out Our Guide to Creating Mental Health Treatment Plans

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