Mental Health Progress Note Sample
This sample mental health progress note was created in 2 minutes using the ICANotes mental health EMR. The only words typed by the clinician are highlighted in yellow. ... This patient is fully oriented. Clinically, IQ appears to be in the above average range. Insight into illness is fair. Social judgment is intac t. There are signs of anxiety. ...
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Mental Health Discharge Summary Sample
www.icanotes.comHas never received outpatient mental health treatment. Suicidal/Self Injurious: Ms. Nesmith has a history of suicidal thoughts but has never made an attempt. Assault History: Ms. Nesmith has been assaultive. She has been in fights but has never seriously injured anyone. Addiction/Use History: Ms. Nesmith has a history of possible alcohol over use.
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www.icanotes.comInstructions / Recommendations / Plan: The risks and benefits of Psychotropic medications were explained to Anna. Cognitive Therapy Relaxation Techniques Start Paxil 10 mg PO QAM (Anxiety) Start Buspirone 10 mg PO QAM (Anxiety) Start Ambien CR 6.25 mg PO QHS (Insomnia) Continue Synthroid 50 mcg PO QAM (Hypothyroidism) ...
Note: This Progress Note was created in ICANotes in 2 ...
www.icanotes.comNote: This Progress Note was created in ICANotes in 2 minutes. Only two sentences were typed, those highlighted in yellow. The rest of the content was generated by clicking buttons to generate personalized narrative text.
templates. The only words typed are highlighted in yellow ...
www.icanotes.comThis group therapy note was created in the ICANotes Behavioral Health EH R . All narrative was generated through menu -driven templates. The only words typed are highlighted in yellow.
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www.icanotes.comPrior Depressive /Manic Episodes: She repor ts that there have been no prior depressive episodes. Mrs. Little does not have a history of manic or hypomanic episodes. Severity/ Complexity: Based on the risk of morbidity without treatment and her description of interference with functioning, se verity is estimated to be moderate.
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www.icanotes.comPsychotherapy Progress Note Mrs. Little seems to have had an inadequate response to treatment as yet. Symptoms of depression continue to be described. Her symptoms, as noted, are unchanged and they are just as frequent or intense as previously described. Mrs. Little describes feeling sad. Mrs. Little denies suicidal ideas or intentions. Mrs.
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www.icanotes.comThis sample SO AP note was created using the ICANotes Behavioral Health EHR. The only words typed by the clinician are highlighted in yellow . Visit http s://www.ICANotes.com for a free trial or demo. October Boyles, LPC 123 Main Street, Suite 202 Anywhere, US 1234 5 Tel: 555 -678 -9100 Fax: 555 -678 -9111 1/30/2019 9: 50 :04 AM
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