TherapyNotes' Psychiatry Intake Note template allows you to capture both a robust biopsychosocial history of your patient and effectively document medical services within a single note.
Psychiatry Intake Notes are connected to appointments when Psychiatry Intake is selected as the Appointment Type. Once a scheduled Psychiatry Intake begins, TherapyNotes will generate a To-Do list item prompting the clinician to create the corresponding Intake Note. To learn more about creating notes and note writing tools in TherapyNotes, read Create a Note.
Note Header
The note header automatically populates information for the clinician, client, and appointment including relevant supervision information, client insurance, and service code. To edit information in the note header, such as the Note Title or Service Code or to add information such as add-on codes, click anywhere on the note header or click Edit in the upper right corner.
Presenting Problem
In this field, you can document the reason the client is attending treatment. This often includes a direct quote from the client describing the primary issue they hope to address, along with some basic relevant information. If the client has previously completed a Client History Form, you will be able to use the History button on the right-hand side of this section to view their response to the corresponding question, and copy their response into this field by clicking the Use button.
Current Mental Status
Here you can document a mental status exam. Use our one-click auto-fill options (All Normal or All Not Assessed) to simultaneously fill each of the fields, or click in each field to select from a list of common responses or enter your own information in each field.
Risk Assessment
The risk assessment section is comprehensive and in line with best practices, especially around assessing suicidality. It is simple to document the full scope of clinical assessment while also incorporating best practices from risk management to serve both you and your clients more efficiently.
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Patient denies all areas of risk: When the client denies all areas of risk and your clinical judgment concurs, select the Patient denies all areas of risk. No contrary clinical indications present checkbox. This shows that you did not simply accept the client denial of risk, but you performed a suitable clinical assessment as well.
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Area of Risk: Click in this field to select from a variety of common areas of risk. You are also able to type any other or more specific areas of risk for your client. You should enter only one area of risk per field so that each area can be assessed independently.
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Level of Risk: An area of risk may be present for your client but may not pose an immediate or grave threat. Level of Risk lets you rate risk as Low, Medium, High, or Imminent, and shows variance in risk over time, providing effective documentation of improvement or times of crisis. Because each area of risk is assessed independently, you can also quickly show where differences exist. This field is required for all areas of risk.
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Intent, Plan, and Means to Act: Documenting these items helps justify your selection of the level of risk and shows that you completed a thorough assessment. Because some items may not apply to some types of risk, each item has Not Applicable as an option. Each item requires a selection for all areas of risk.
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Risk and Protective Factors: Click in these fields to display a list of relevant common factors that may increase or decrease your clients’ level of risk. Choose as many as applicable to each area of risk or add your own items specific to your client.
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Additional Details: Enter any relevant additional details not already addressed in other sections.
- Multiple Areas of Risk: If multiple areas of risk apply to your client, you can document each area separately. Use the +Add Area of Risk link at the bottom to add another set of fields to the note template. You can reorder these groups or remove them entirely by using the up/down arrow and "X" to the right of each Area of Risk. Unless the Patient denies checkbox is selected, there must always be at least one set of fields. Clicking the “X” will not remove the fields if there is only one group but will clear out all existing entries and allow you to start over.
Vital Signs
You can choose to document as many or as few vital signs as you measured in session. For fields such as height, weight, and temperature, select the appropriate units for your measurement from the dropdown menu first. TherapyNotes will remember which units you use in future notes. Use the slider to indicate the client-reported level of pain.
Review of Systems
To make it easier to document effectively for E/M coding, record any information about your review of systems here. The placeholder text provides a prompt of a psychiatric review of systems, but you can also choose to document a more traditional review of systems (constitution, HEENT, pulmonary, CV, etc.) as well.
Objective Content
An intake appointment involves much more than simply gathering a client history. You will most likely take time to review policies and procedures, obtain consent for treatment, develop rapport by discussing a variety of topics, and so on. Document what occurred in the session here.
Biopsychosocial Assessment
- This is where you can document your client’s relevant history. Placeholder text in each field prompts for what type of information you may want to include in that area.
- The History button at the top allows you to pull information from the Client History Form or prior Psychiatry Intake notes into all fields simultaneously or use the button next to each field to select one at a time.
- The Other Important Information field allows you to readily document additional information that impacts treatment which may not be represented in other fields above. This may include information specific to your modality of practice or requirements from licensing boards or insurance payers.
Allergies
List any actual or suspected allergies the patient may have here. You can document the type of reaction and its severity for each allergen. You may also choose to document adverse drug reactions in this field.
Medication
You can search or manually enter medications in the Medication field. As you type, TherapyNotes will suggest common generic, brand-name, and supplement medications (including dose and form) powered by the Unified Medical Language System® (UMLS) RxNorm database, which is updated monthly.
If the medication you need isn’t listed, you can simply type the full name to add it as a custom medication.
Once a medication has been selected or entered, click outside of the field for additional fields to display. You can then enter details such as dosage, frequency of administration, Symptoms Being Treated, Reason for Adding, and Additional Instructions. These fields are optional.
Medications/supplements from previous notes or the Client History Form will be pulled into subsequent new notes from the most recent past note or form. To pull reported medications from older notes, select the History button. Click the Use button to pull this information into the current note. Review and edit the information as necessary.
Medication management clinicians can mark each medication as reviewed, edited/corrected with a reason, or marked as stopped with a reason.
- Reviewed: Acknowledge the medication, medication remains active.
- Edit/Correct: As the non-prescribing clinician, correct the recorded information from the patient for accuracy (e.g., patient made an error when reporting it).
- Adjust Rx: As the clinician who prescribed the medication, adjust the medication details (e.g., dose or frequency).
- Stop: Stop prescribing/recommending the entered medication/supplement or patient stops it on their own accord. A reason can be entered for stopping the medication.
Just like the previous set of fields, you can enter medications you prescribe by selecting the Prescription radio button. There is no need to document the prescribing provider, because you are the one signing this note. These medications will automatically pull forward into future Psychiatry Session and Psychiatry Intake notes, allowing you to see the current medications at a glance.
For medications prescribed by others, select the Reported radio button to trigger the Prescribed By field. Use these fields to document medications the patient is currently taking that are prescribed by other providers.
To add more complex instructions such as titrations for medication, click the + Additional Instructions button to open a new field and enter them.
Medication Notes
Here you can document any specific discussions you had with the patient about their medications. You can also document any interactions they may experience, any probable side effects, rationale for selecting specific medications or classes, or any other relevant information.
If new medications were not added to the note, use the checkboxes to quickly document that you reviewed all the listed medications with the patient and that no changes in their medication were needed.
If new medications were added to the note or any existing medications were adjusted, use the checkboxes to quickly document you reviewed and explained any changes in medications with the patient.
eRx Medications
For clinicians using ePrescribe with DrFirst, any medication updates made in the patient’s eRx tab will automatically populate when creating the note. These medications cannot be edited or removed within the note. To make changes to the populated medications, select Update eRx to access the patient’s eRx tab. Once the changes have been made, return to the note and select Refresh Medication List for the updates to appear.
To manually correct medication details received from DrFirst in a note, select Edit Meds Manually. Any changes you make will be saved only to the note and will not update the ePrescribe record or affect medications in DrFirst. This option may only be used when the medication information from DrFirst does not reflect what was intended to ensure accurate documentation.
Non-eRx Medications
When completing a subsequent Psychiatry Intake Note, recorded medications and supplements will appear in a single list within notes, organized by prescriber. Medications prescribed by the note’s author will appear first, followed by those prescribed by others in alpha-numeric order.
Plan
Document the next steps in the treatment process, whether it is to contact other providers to obtain records, coordinate with primary care, or just follow up with the patient at a later date.
Diagnosis
You can begin typing in the ICD-10 field if you know the appropriate code for the patient diagnosis. These fields also feature searchable DSM-5 diagnoses, allowing you to easily find diagnoses.
Sign and Save
Once you have completed your Intake Note for the session, select the Sign this Form checkbox to electronically sign the note and click the Create Note button.
Electronic signatures are captured in accordance with appropriate requirements. Multiple factor authentication is required to identify the user signing the note. The application automatically captures the timestamp for the signature as well. Electronic signatures cannot be edited or modified.
If the document is placed in draft mode and then re-signed, the signature on the note will reflect the most recent electronic signature captured. You can view other signatures, including the timestamp of the first signature on the note, using the Note Revision History. All actions related to note signatures are captured in the activity log for the practice.
To save an unfinished Intake Note, leave Sign this Form unchecked and click the Save Draft button. You may access your draft Intake Note later from your To-Do list or click Patients > Patient Name Documents tab.