To mental and behavioral health care providers, therapy notes are essential for documenting patient encounters. What’s more, therapy notes are consistently cited as a top-requested electronic health records (EHR) software functionality by buyers who contact Software Advice.
There are hundreds of solutions that offer therapy notes for practitioners looking to make a first-time or replacement purchase. To help you narrow down your options and better understand what’s available in today’s market, we put together this buyer’s guide.
Here’s what we’ll cover:
“Therapy notes” can refer to several different kinds of medical forms that are needed to document patient encounters in mental and behavioral health care settings.
These can include:
These types of mental health progress notes are essential for practitioners to record patient assessments, treatments and results over time. The data can also be used for tracking and coordinating care to achieve healthy outcomes. And in some cases, these notes serve as the official record of the patient relationship and may be subpoenaed in court.
In light of all this, it’s extremely important for therapy notes to be as comprehensive, up-to-date and secure as possible. Indeed, the right software ensures notes are legible and automatically marked with time and date stamps. Drop-down menus and templates make it easy for practitioners to enter detailed patient observations. Plus, electronic files are generally more secure than paper-based records.
|Specialty-specific notes templates||Most systems should offer notes templates for a range of specialties, such as psychotherapy, psychiatry and behavioral health. Some allow users to customize templates with additional fields/terminology. Templates usually offer drop-down menus and click-boxes.|
|Note management||Allows users to easily view/retrieve notes and assessments, in order for human services specialists to access old notes and review previous sessions.|
|Outcomes tracking||Allows users to turn therapy notes data into reports, for gauging health outcomes across patient populations. (Measuring care outcomes is recommended by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [DSM-5].)|
|Coding tools||Help users select and enter codes in note templates and billing modules from a pre-programmed menu or searchable database. These clinical documentation codes may include CPT, ICD and/or DSM codes.|
|Staff management||Users are assigned roles within the system (e.g., site administrators, clinicians or billers) that provide different levels of access (e.g., clinicians can only see the notes for their own patients). Supervisors can receive missing notes reports and notifications for notes that need approval. Standard functionality for systems aimed at larger organizations.|
Some of the benefits of electronic therapy notes should already be clear from our discussion, but here’s a complete listing:
Stand-alone or “best-of-breed” programs can be implemented to create, edit and store different kinds of therapy notes. Vendors of this type of software often offer tiered pricing plans.
For example, at the first, most basic tier, buyers might pay a monthly fee allowing a small pool of users access to basic functionality and services, such as progress notes templates, document storage and limited email support from the vendor.
At the higher-priced tiers, buyers might be able to add more users to the system and/or to access more advanced functionality or services beyond what the lower tiers provide. These additional capabilities might include reporting and analytics, electronic claims submissions or live phone support from the vendor.
Buyers seeking a more comprehensive deployment strategy can implement a therapy software suite that includes other capabilities in addition to therapy notes. For example, an EHR suite may also offer billing, patient scheduling and human resources applications. Pricing for these suites can be much more expensive, as they offer a greater breadth of both clinical and practice management functionalities.
Your choice between a best-of-breed system or integrated suite will come down to the size of your practice, your budget and whether you want your solution to integrate with other software.
You will likely come across some of the following market trends as you begin your search for therapy notes software:
Cloud-based deployment. One of the most important choices buyers need to consider is whether they’d like a cloud-based or an on-premise solution. The cloud model provides Software-as-a-Service (SaaS), in which the system is hosted on external servers and accessed remotely through the Web. In on-premise systems, the software is hosted on the practice’s own servers and must be updated and maintained locally.
Cloud-based EMR mental health systems are becoming increasingly popular. Not only do they offer the flexibility of remote access, they also involve lower upfront costs, and updates and maintenance are handled by the vendor.
Mobile device support. Support for wireless devices, such as smartphones and tablets, is becoming common among mental and behavioral health software vendors. The convenience and portability of such devices makes them ideal for reviewing progress notes and managing scheduling changes on the go. Some vendors are even introducing HIPAA-compliant native applications for Windows, Android and/or iOS devices. What's more, a report conducted by Software Advice finds that mobile users cite higher levels of satisfaction and fewer challenges with their EHR than non-mobile users.
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