Accurate, current, detailed documentation and note-taking are critical to ensuring patient progress in mental health care settings. But what’s wrong with paper documents, which have long been the go-to for tracking client progress and creating treatment plans?

Paper files, for one, can be easily compromised, posing potential dangers to privacy. Sensitive paper-based documents may also be inconvenient for modern therapy practices. And on top of all this, creating paper documents, then digitizing them adds several steps to a critical documentation process. Fortunately, we now have better solutions – therapy notes software.

So, when it comes to psychology notes, let’s take a look at some better ways to create, store, review, and share data without compromising security.

What is Psychology Notes Software?

Psychology notes or therapy notes refer to a variety of medical forms that are used to track patient encounters and patient progress in mental health care settings.

These notes provide clinicians with a conceptualization of the patient’s condition and progress so far, among other things.

Some different types of psychology notes include:

  • Patient intake forms
  • Therapy progress notes
  • Psychotherapy notes
  • Psychological evaluations
  • Treatment plans, and
  • Discharge papers

Why Do Therapy Notes Matter?

Creating, securing, and storing these different forms is critical for running a mental health care facility. [1] Forms create a log of the patient’s encounters with healthcare providers and also give treating clinicians valuable insight into the patient’s condition, diagnoses, prognoses, and progress.

Psychology notes or therapy notes refer to a variety of medical forms that are used to track patient encounters and patient progress in mental health care settings.

The data gathered with these essential psychology notes help providers coordinate their care and treatment while also tracking patient outcomes.

In many cases, these documents become the official record of a patient’s relationship with their providers. The files are kept confidential and are protected under specific privacy and security laws; however, files can be subpoenaed in court if particular circumstances arise.

How Do They Work?

Because psychology notes are so important – as any practitioner will know – they need to be comprehensive, current, and privately stored.

Smoother Practice Management

Today, therapists have the advantage of using cutting-edge therapy notes apps and software to help streamline these processes by securely:

  • Creating notes from templates – often, these can be found as discipline-specific templates, e.g. telepsychiatry notes, online coaching plans, and or fitness charts.
  • Securely storing notes in one searchable, organized database – digitized files often solve some of the structural problems that are inherent in traditional paper-based filing systems.
  • Transferring these documents – Coupled with file-sharing capabilities for intra-team and patient-practitioner communications, the right software is designed to considerably boost practitioner efficiency.

Time-Saving and Efficiency

Other technological features also aim to overcome some of the smaller but more common drawbacks of traditional, hand-written notes:

  • Comprehensive therapy notes apps also will, and should, ensure that notes are easy for different providers to read. Paper notes are often handwritten, and some providers may have illegible handwriting, which can cause problems with continuity of care.
  • Therapy notes software can also make it easy for providers to create new patient notes and documents with intuitive drag-and-drop interfaces, templates, and pre-populated forms. The right type of therapy notes software should ensure documents are kept in strict compliance with security provisions, an important consideration given the confidential nature of many telehealth services.

Often designed by clinical or mental health experts to address specific practical problems, therapy notes apps – like other mental health apps – are built for therapists, counselors, and coaches.

But even with a good overview of their practical features, there are a few more things to know before making an upfront investment in your practice management.

Features of Psychology Notes Software

The most popular and helpful therapy notes software programs share several core features that providers must understand. For one thing, most therapy notes software systems are cloud or web-based, often in Software As A Service (SaaS) form. [2]

What’s the difference? Very briefly:

  • Cloud-based EHR and behavioral health systems ensure providers do not have to manually update the systems or host the operations within their organization. This makes cloud-based therapy apps – including note-taking apps – more affordable and user-friendly for even small, solo practices. Naturally, cloud-based systems are popular and will continue to evolve and become more common. They generally offer organizations flexibility and are typically cheaper to purchase.
  • Larger organizations, however, can also benefit from cloud-based therapy notes software. It’s also possible to find programs that can be housed on-premise if needed. We’ve mentioned a few more of the differences between on-premises (SaaS) and cloud-based software below. [3]

Choosing Your Solution: What To Look Out For

The table below covers some other common features that practitioners can find in therapy notes apps.

Feature

Practitioner Benefit

Specialty-Specific Note Templates

  • Many therapy notes software vendors offer a selection of note templates for different areas of practice. Examples include note template programs for behavioral health, life coaching, psychiatry, and psychotherapy practices.
  • Specialty-specific programs often also include industry-specific insurance codes and formats for more efficient document creation and editing.

Psychology Notes Management

  • Notes management features allow providers to quickly and easily view or obtain therapy notes and other documents.
  • Many software systems also provide access to records for multiple authorized persons, allowing them to be shared with a team of treating clinicians.

Outcome Tracking

  • The ability to turn therapy notes into reports allows providers to assess and analyze health outcomes for different patient populations.
  • For telepsychologists, the DSM-5 recommends that providers measure care outcomes; outcome tracking makes it easier for mental health clinicians to meet this goal.

Coding Tools

  • Convenient and easy-to-use tools help providers enter critical billing codes more accurately and efficiently.
  • When they come with a pre-programmed menu and searchable database, practitioners stand to save time finding correct codes.
  • Therapy note apps also often contain practice-area-specific documentation codes, such as CPT, DSM, or ICD codes.

Staff Management Capabilities

  • Incredibly helpful for organizations with multiple staff members, staff management tools allow each employee to be assigned a role within the software system. Examples include assigning positions for site administrators, billers, or counselors.
  • In more advanced systems, assigned positions offers pre-set levels of authorized access, so clinicians can only see notes for their specific patients.
  • This feature is a standard function for psychology notes software that is designed for larger organizations like hospitals or outpatient care facilities.

How Does It Help? Benefits for Practitioners

Therapy notes software can improve treatment outcomes, continuity of care, and also make clinical tasks easier and more efficient for providers.

And there are more practitioner benefits to using therapy notes software. For example:

  • Therapists can avoid spending valuable time on double-entry. Instead of creating a paper document and then needing to digitize it, providers can make the document once as an electronic file.
  • Providers can go to a paperless office, lowering their overhead and increasing their savings. Plus, going paperless makes eco-friendliness for a therapy office an attainable goal.
  • Going digital often means better organization. As a general rule, digital psychology notes these days are automatically organized within note-taking systems. The staff does not have to spend their time correctly dating and timing the document and assigning it to the correct patient file. Instead of hunting through a file cabinet for the right document, it’s simple and lightning-fast to find it within the digital system.
  • Software programs allow providers to access patient analytics. It’s much easier to use digital files and systems to automatically create historical reports on patient progress than it is to make charts out of paper files.
  • Coding is made easier with therapy notes software. The tedium of finding the correct codes is eliminated when providers use digital solutions instead of paper filing systems.

Choosing The Right Software For You

Don’t fret if you’re a smaller organization or solo practice – while upfront costs can typically be quite high, you don’t always have to pay for a robust system.

Rather, there are many standalone therapy notes software programs tailored for small organizations such as sole traders and start-ups, as well as free trials for most respectable software.

Pricing

Vendors for standalone therapy apps often price their plans with a tiered system, so organizations can avoid overpaying for features they won’t need or ever use. For example:

Basic pricing tiers:

Some of the most foundational pricing tiers and plans cost a monthly fee. These basic plans tend to offer therapy notes system access for a small group of authorized persons. In addition, expect most entry-level features and functions found in therapy notes software, such as (but not necessarily limited to):

  • Psychology progress note templates
  • Secure note storage capabilities
  • Limited customer service support from the vendor.

Higher Tiers

Tiers that cost more will often offer more access to a larger group of users, alongside:

  • Unlimited customer support
  • Electronic claims submissions, and
  • Analytics.

Shopping Around

As a practitioner, it’s also advisable to also shop around for therapy software suites. Along with the therapy notes features, these frequently include other automated capabilities. Some of the most popular EHR suites, for instance, entail:

  • Billing
  • Scheduling
  • HR applications, and
  • Client management programs.

Often, suites are far more expensive than standalone programs that are priced on a tiered system. For hospitals and outpatient facilities, comprehensive therapy notes EHR suites are best to deploy.

Choosing the right therapy notes software for an organization will require an understanding of the system’s features; its precise needs, processes, and how your patients can benefit as well.

Budgetary needs will also figure into the equation, as will the organization’s size and the number of staff. In some cases, standalone therapy notes software can integrate into an organization’s current client management system or other software.

Understanding the Tech: Features and Trends

Technology is constantly and quickly evolving. What was technologically possible for providers just ten years ago often seems primitive today, and as we’ve seen, automation and client management software can greatly simplify a therapist’s job.

However, there are several market trends that you as a therapist will want to understand, so you can make better decisions about choosing a therapy notes application for your specific practice.

We’ve summarized some of these market trends below, to help you look out for them when shopping around:

Trend

Importance

SaaS

Software-as-a-system or SaaS is a type of technology where the system is hosted on an external server, then accessed via the internet. These systems are also called cloud-based deployment. With on-premise systems, therapy notes programs are hosted on the organization’s own server. Often, practitioners must update and maintain the system themselves.

Customer Support

One drawback of SaaS – providers won’t always offer 24/7 support, and systems don’t automatically update or maintain itself as cloud-based systems might. Look out for platforms with all the help and guidance you need; many these days prepare videos, tutorials and live chats to help those who aren’t so technologically inclined.

Mobile Compatibility

Another market trend with psychology notes software is mobile-compatibility. [4] Smartphones, tablets, and of course, apps are becoming incredibly popular with patients and therapists alike. As such, more and more therapy notes software vendors are including support for these types of devices in their applications. Accessing the system via a mobile device makes it easier for providers to manage patient schedules and review and share their psychotherapy progress notes.

HIPAA-Compliance

With the last point in mind, and with the rising popularity of video therapy, vendors are introducing HIPAA and HITECH compliant applications for a range of systems, such as iOS, Windows, and Android. [5]

Popular Therapy Notes Software For Practitioners

TherapyNotes is just one example of a versatile, cloud-based e-therapy suite designed for practitioners of any size. However, its many templates make it a good case study for a therapy notes software. It features several vital components for documentation and filing processes for therapists, including scheduling capabilities, billing, note templates, and optional unlimited, free phone support.

A key benefit of the program is that it was explicitly created for mental health practitioners – all data is thus kept in compliance with security standards established by HIPAA and PCI. [6] Full data encryption, which adds an extra, tight level of security, is present on TherapyNotes external servers and network. TherapyNotes makes note-taking much quicker, gives providers multiple calendar views, and streamlines workloads.

Software

Details

TherapyNotes SoftwareTherapyNotes is scalable and thus built for mental health or coaching practitioners of all sizes. Features include:

  • Vendor support
  • Invoice and claims management
  • Calendars, Reminders, and Scheduling
  • Patient portal
  • Clinical documentation
  • Electronic Medical Records (EMR)
  • Form-based note, evaluation, and treatment plan templates
  • Practice-specific templates for psychiatry, counseling, therapy, social work, and psychology.
NameTherapyNotes
PriceOn request
Good ForEHR, Practice Management, Billing
Websitehttps://www.therapynotes.com/

Final Thoughts

So, should you as a practitioner use an app or software program to help your clients?

As technology evolves and the popularity of psychology apps grows too, mental health professionals will need to weigh the benefits and limitations of therapy notes software. With psychology notes software, providers can offer continuity of care, find more time in the day, and lower their overheads with streamlined software and automated processes. However, implementing new software programs is not without its challenges, at least in the beginning.

Organizations must take their staff member’s needs and opinions into account when shopping for a provider. Ease-of-use is essential for cutting down on staff training time. In addition, software programs that include client portals must also be evaluated for user-friendliness.

Have you recently implemented psychology notes software for your practice? How did you go about finding the right vendor for your organization? Feel free to share your experiences in the comments section below.

References

  1. ^ Fernández-Alemán, J. L., Señor, I. C., Lozoya, P. Á. O., & Toval, A. (2013). Security and privacy in electronic health records: A systematic literature review. Journal of Biomedical Informatics, 46(3), 541.
  2. ^ Adibi, S., Wickramasinghe, N., & Chan, C. (2013). CCmH The cloud computing paradigm for mobile health (mHealth). The International Journal of Soft Computing and Software Engineering, 3(3), 403.
  3. ^ Cusumano, M. (2010). Cloud computing and SaaS as new computing platforms. Communications of the ACM, 53(4), 27.
  4. ^ Luxton, D. D., McCann, R. A., Bush, N. E., Mishkind, M. C., & Reger, G. M. (2011). mHealth for mental health: Integrating smartphone technology in behavioral healthcare. Professional Psychology: Research and Practice, 42(6), 505.
  5. ^ United States. (2004). The Health Insurance Portability and Accountability Act (HIPAA). Washington, D.C.: U.S. Dept. of Labor, Employee Benefits Security Administration.
  6. ^ HIPAA Journal. (2020). PCI and HIPAA Compliance Comparison. Retrieved from https://www.hipaajournal.com/pci-and-hipaa-compliance-comparison/

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