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Custom Encounter Notes for Psychotherapists

Not all Practice Fusion users are physicians or other providers who would be entering in typical medical data such as vitals. It would be more appropriate for this information to be asked for ONLY in encounter notes completed by those providers needing to use a template that requires it. Psychotherapists for example, would not need this information and generally do not use such information in the daily work of their practice.

Furthermore the SOAP note is somewhat out of date for many psychotherapists. Many are not being encouraged and/or were trained on DAP style notes. It would be best if we could free text or more easily design our own note template for the information we need in our note. Generally third party payers need the chief complaint, some information on current symptom status, diagnosis, follow-up plan, and info on what interventions were used. Beyond this---allowing provider to create his/her own note template is extremely helpful.

I'd recommend you use the mental health questionnaires that are validated and free for provider use as noted through SAMSHA/NIMH/NIH sites---these would include: PHQ-9, GAD-7, Columbia Suicide Risk Assessment, AUDIT (alcohol screening), DAST-10 (Drug screening), etc. These are better understood by many non therapists/mental health professionals and so integration of care through the EMR will be more streamlined. These should be allowed to be easily embedded into our notes.

Since the HCFA 1500 is the standard billing form---it would be really great if this form was available as part of the encounter or that could be included with the encounter for any patients submitting claims on their own after providing self-pay for services or to allow providers to more easily submit claims on behalf of patients.

There needs to be an easier way if a mistake was entered by a provider setting up their account to also tell the system it does not use certain functions---I am in a frustrating position of continuing to be stuck on step 3 of 3 with e-prescribing---I do not know how I got there or what happened by I'm stuck there and I cannot tell the system (and your help desk technicians are unable to tell me either) how to stop getting prompts to set this portion of my account up---it's irksome and I strongly believe there is a better set up that would have avoided this.

That said---I also appreciate the feedback and support I have gotten---it is timely and helpful. And I also respect that creating an EMR all providers like and can easily use is no small feat and appreciate the overall user friendliness of a system that is also free to me as a private practitioner.

170 votes
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Nicole shared this idea  ·   ·  Admin →
Acknowledged  ·  Matthew Douglass responded  · 

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27 comments

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  • Mrs Brenda Johnson commented  · 

    I would like a box that is part of the record for psychotherapy notes that could be excluded when releasing medical records. A separate note can be done however not very efficient.
    Would like to be able to use templates in all areas of dictation. Under diagnosis, care plan, and extra screen.

  • Steve Romm commented  · 

    I agree 100%. This needs to be done to make practice fusion really helpful for therapists.
    steve romm, Psy.D.

  • Jo Eckler commented  · 

    I love this idea--please implement it! I would recommend this product to so many colleagues if you do.

  • Anonymous commented  · 

    Mental and behavioral health should not be excluded from the practical use of this product. Mental health and addiction disorders cut across all medical systems as root causes of acute care issues, and these chronic diseases deserve the same attention in the EMR market. As a leader in technology with Practice Fusion please incorporate our needs for effective and integraated charting. Thank you!

  • Anonymous commented  · 

    Please, please address the concerns of mental health providers utilizing Practice Fusion. We need to have templates and charting options that reflect the services we provide. I agree with another writer that the suggestions have been offered a variety of times with slightly different wording and together demonstrate a viable upgrade suggestion.

  • Mr Brandon Ford commented  · 

    I think this question has been quite popular and asked in many different ways. I hope that this can be implemented early in 2016. Any thread that even mentions "mental Health" or "therapy" most likely aligns with this request. Please add up ALL of those votes and threads to see how needed this is.

    Thanks,
    Brandon

  • Ms Susan Valentine commented  · 

    Agree. I am not a doctor. Need to be able to delete items I do not use. I do not take vitals. I do not need labs, vaccinations, pharmacy, food allergies, etc. How can I delete the yellow notifications section at the top? I have been able to create my own soap note that works for mental health. I use the S only to indicate it was a individual session then I write the rest in O. It is time consuming to recreate the Beck Anxiety/Depression scale each time it is used. I've spent hours creating and recreating my own templates in Practice Fusion.

  • Jennifer Falbo-Negron commented  · 

    I agree and hope that this sort of template will be available soon. I just joined Practice Fusion and would like to use it as my online system for clients files--intake, progress notes, etc.

  • Dr Christopher Lucas commented  · 

    implementing standardized rating scales (e.g. PHQ-9, GAD-7, ADHD-RS) - especially in flowsheets so you can track progress over time would be an awesome addition

  • Dr Janice Archer commented  · 

    Excellent and well written. Unfortuanately , It is too little to late. I am being denied payment because I am not using the {Gola Orienter" format and measurements. It is difficult and time consuming to build a template, plus , add the testing to the notes, but, If I understand preperly , if I up load a "document" the document does not go to the patient "notes" section of the chart. Please try to enable the teting forms and the goal oriented templates as soon as possible. at least to up load test results to chart notes.

  • Dr Janice Archer commented  · 

    I would like to be able to include the "behavioral health" testing for depression, anxiety, Bipolar etc. in the notes.

    Also insurances want "Goal" charting for notes and the progress onn goals. I have several templates I can use but, they are too lengthy to hand enter into the tmemplate formate. I would like to be abel to Import the test results, with the resulting "goals of treatment" than be abel to carry forward into the next session with the progress toward "goals" UBH" recently denied several claiims because the notes were not " showing progress toward goals" I know that UBS in RI is breaking the parity law. BUT, with that said,, I need payment and I am being denied. Now I will have to hand import , but, it is next to impossible to import into the charts notes test results , and the forms I already now have, to complete UBH requests. the denia came due to my using SOAP notes and using Paragraph format. Optum and other insurances are making these requests. PLEASE consider another format of entering templates and test results ets. thanks Jan Archer

  • Dr Jane Rider commented  · 

    Psychotherapy notes are held to a higher standard of confidentiality than other medical notes. They must be kept separate from the rest of the note. Of course diagnosis, lab, medications do not have the higher standard of confidentiality. We need a method to put part of the note or some of the notes on a higher security level than the rest of the note or notes both for personnel access and records requests.

  • Dr Janice Archer commented  · 

    Forgot, I have to upload and tets Beck Anxiety, PHQ 9 etc then move to chart, it is a royal pain, BUT< i can print out for insurance Co. if they want to complete authorization for treatments

  • Dr Janice Archer commented  · 

    I am in the same pssotion, psychiatry, I also prescribe. I have a template I made with symptoms, stated ones, my perception, then I adde: Goal: list goals Pt % toward goal # 1 etc. ; Symptom response Expected resolution: Chronic managed with meds , of acute managed with CBT etc. or meditation list different treatment methods and click the ones I want. expected duration of treatment: Any hlep you can give I would appreciate.

    Making my own temmpates are the best I can o right now. It is time consummg, but, in the end saes me time. I have Insurance complanie denying treatment unless, I state goals, and the progres toward goals, and what tretment is being used et. I have UBH on my back all the time. they donot undertan {arity law" AT ALL> they deny "payment" rather than treatment, and wnt "MEASURABLE goals" wht ever thowe are .?? Ok so Pt. nnow sleep 4 hours per night rather than two hours etc ??? Psychiatry right now is a mess. any help with charting I will accept ASAP!!

  • Cheryl Mazur commented  · 

    Agreed. Cutom notes for other purposes like phone messages and other should not be in a SOAP Note format we need the ability to note other information in the chart, like when a pharmacy calls to alert our office of duplicate prescriptions for pain from other offices.

  • Samantha Afanador commented  · 

    I would love the ability to create a treatment plan within practice fusion and have that treatment plan automatically populate like other features do.

  • Cherrell commented  · 

    Agreed xs 100! While I appreciate the features of PF, I wish it were more counselor friendly. Especially the ability to have an online scheduler despite not having eRx ability.

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