Note-taking is an essential and valuable component of any behavioral health provider’s job. Comprehensive notes that reflect a complete picture of the client’s time with you overflow into every other process. From forming treatment plans to tracking their progress, note-taking helps providers offer better care.
Therapy notes are valuable because:
They Are More Reliable
Rather than depend on memory alone, therapy notes provide a dependable source of data for providers to recall information, track client progress, and make connections through the duration of the individual’s care.
They Are a Detailed Record
Should this information need to be reviewed by another party (like a future provider), progress notes provide a detailed record of the client’s time with you, what has been accomplished, what interventions/modalities have been implemented, what has worked for that individual and so much more. Having a reliable, detailed account of the patient’s history and progress sets them up for success in the future.
They Help Formulate Treatment Plans
With a detailed record of the client’s progress in hand, behavioral health providers can make well-rounded decisions and formulate data-backed treatment plans. They can collect the individual’s symptoms, behaviors, thoughts, and more to diagnose and treat clients to the best of their ability.
They Keep Everyone on The Same Path
With an integrated EHR/client portal, a client, their current provider, and any future provider can stay on the same path. Clients can better understand their progress, ask essential questions, and get more involved. Future providers have access to a detailed client record should the individual need to be referred out for any given reason. Therapy notes are essential.
With so much value being placed on progress notes in therapy, providers need a highly effective method of completing their notes and collecting this data. There are behavioral health EHRs integrated with Wiley Practice Planner, which are explicitly designed with this in mind. Integrated therapy notes, including SOAP notes and BIRP note templates, are easy to complete directly within the individual’s electronic chart. That information then remains easily accessible, meticulously organized, and conveniently located all in one place should you need them in the future. Providers can also find the most up-to-date set of diagnostic codes, treatment plans, discharge summaries, and more.
Not only this, but an integrated system allows clients/patients to review progress notes so that they can play a more active role in their behavioral health care. Just like progress notes help you remember your encounters, they help clients stay on top of the details as well. With this access, they can remember what they need to do to stay on track with their treatment plan, ask questions that they didn’t think to ask during a visit and recall the information discussed during your time with them.
Integrated therapy notes in a behavioral health EHR improve client’s care by helping providers keep track of the interventions that have been implemented, the discussions that have been had, and the progress a client has made while also assisting the provider in staying organized in their administrative responsibilities.