Mobile Notes - Note Templates - Progress Notes

Expand the list of contents and notes for the following documents: 

Group Therapy Note

  1. Header
  2. Group Therapy - Group Notes
  3. (This section is used to capture data from group appointments with multiple patients.)
  4. Group Therapy - Patient specific
  5. Group Therapy - Last Session Homework
  6. Assessment - Diagnoses
  7. Review
Notes
  • The "Group Therapy - Group Notes" section allows you to create content that is common to all patients in a group session
  • To use:
  1. Create multiple appointments (one for each patient in the group) with the same provider, day, start time, and end time
  2. Start the Group Therapy Note for one patient in the group, and in the "Group Therapy - Group Notes" section write content that is common to all patients in the group
  3. The other sections in this note are specific to this patient only
  4. Sign & Close the note for the first patient before starting the notes for any other patient
  5. When you start the note for each remaining patient, you'll see that the "Group Therapy - Group Notes" section has been prefilled with the content you entered for the first patient
Please download the attached documentation at the bottom of this page. 


Marriage and Family Therapy Progress Note

(Designed in partnership with and endorsed by the American Association for Marriage and Family Therapy (AAMFT))
  1. Header
  2. Presenting Problem - Intake
  3. Presenting Problem
  4. Measure Review
  5. (Any measures that are assigned to the patient will be included here for review)
  6. Exam
  7. Family Configuration
  8. Family System Functionality
  9. Individual Function and Dysfunction
  10. Systemic Assessment
  11. Assessment - Diagnosis
  12. Interventions
  13. Treatment Plan
  14. Plan - Next Appointment
  15. Review
Notes
  • "Presenting Problem - Intake" contains the content that the patient submitted from the MFT Clinical History Form and/or you (the provider) contributed when filling out the Marriage and Family Therapy Intake Note. It is provided for your reference. It can be removed from your final note by clicking the trashcan on the section tab (which removes the section only for this progress note) or by deleting the content of the section (which removes the content of the section from all future progress notes for this patient).
  • "Presenting Problem" is a separate section for ongoing use in the progress note.


Psychiatric Progress Note

  1. Header
  2. Persons Present
  3. Meds & Allergies
  4. Chief Complaint
  5. HPI/Interval History
  6. Measure Review
  7. (Any measures that are assigned to the patient will be included here for review.)
  8. Stressors
  9. Past History
  10. Review of Systems
  11. Side Effects
  12. Adherence
  13. Vital Signs
  14. Exam
  15. Review of Measures
  16. Lab Results
  17. Sources of Information
  18. Assessment - Sources of Risk
  19. Measure Review - Suicide Ideation Subscale
  20. Suicide Risk Factors
  21. Suicide Protective Factors
  22. Suicide Prevention Plan
  23. Assessment - Diagnoses
  24. Assessment - Impression
  25. Assessment - Alternatives Considered
  26. Assessment - Informed Consent
  27. Counseling and Coordination of Care
  28. Psychotherapy
  29. Plan
  30. Plan - Med Changes
  31. Plan - Labs Ordered
  32. Plan - Next Appointment
  33. Review


Therapy Progress Note

  1. Header
  2. Measure Review
  3. (Any measures that are assigned to the patient will be included here for review.)
  4. Treatment Approach
  5. Last Session Homework
  6. Session Focus
  7. Interventions Utilized
  8. Family and Environmental Strategies
  9. Suicidal Ideation
  10. Clinical Global Impressions
  11. Homework
  12. Exam
  13. Assessment - Diagnoses
  14. Assessment - Alternatives Considered
  15. Therapy Plan
  16. Plan - Next Appointment
  17. Review


SOAP Note

  1. Header
  2. Measure review
  3. (Any measures that are assigned to the patient will be included here for review.)
  4. Meds & Allergies
  5. Subjective (SOAP)
  6. Objective (SOAP)
  7. Exam
  8. Assessment (SOAP)
  9. Assessment - Diagnoses
  10. Plan (SOAP)
  11. Review
Notes
  • A simple note containing only Header; any outstanding measures; Meds & Allergies; Subjective (free text); Objective (free text); Exam; Assessment (free text); Diagnoses; and Plan (free text).
  • Not typically used for time-based E&M services of 99213 or above.


Structured Therapy Progress Note

  1. Header
  2. Persons Present
  3. Session Focus
  4. EB Treatment Approach
  5. Dialectical Behavior Therapy
  6. Anxiety-related Disorders
  7. Child and Adolescent
  8. Eating & Weight-related Disorders
  9. Last Session Homework
  10. Vital Signs
  11. Suicidal Ideation
  12. Risk Factors
  13. Protective Factors
  14. Plan - Suicide Risk Assessment
  15. Clinical Global Impressions
  16. Homework
  17. Exam
  18. Assessment - Diagnoses
  19. Assessment - Alternatives Considered
  20. Therapy Plan
  21. Plan - Next Appointment
  22. Review
Notes
An alternative to the Therapy Progress Note, specially designed for providers who use structured therapies. Differences from the Therapy Progress Note include:
  • Specialized sections for evidence-based treatments in: Dialectical Behavior Therapy; Anxiety-related Disorders; Child and Adolescent; and Eating and Weight-related Disorders
  • Treatment Approach section includes drop-down lists with dozens of principle-driven and manualized therapies to choose from
  • Suicide Risk Factors, Protective Factors, and Risk Assessment sections


Downloads

Group Therapy Note.pdf


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