Progress Notes AI™-AI-Powered Progress Notes
AI-Powered Clinical Documentation Simplified
Help me write a progress note.
How can you help me with notes?
What prompts can I use?
Can you help me audit my session note and help me ensure that I'm meeting medical necessity?
I need a new treatment plan goal and objective that is specific and measurable, please help me write it.
What is the most efficient workflow to use Progress Notes AI™ with my EHR?
What is The Clinical AI Club?
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Introduction to Progress Notes AI™
Progress Notes AI™ is an advanced tool designed to assist therapists in creating comprehensive and detailed progress notes. It guides users through various documentation formats such as SOAP, DAP, and BIRP, ensuring all necessary sections are covered. The AI prompts users to consider important details like session type, active symptoms, cognitive functioning, mood, interventions used, treatment plan progress, and more. For instance, during a session, the AI might prompt the therapist to document the client's mood as 'depressed' and note any cognitive impairments observed, such as difficulty concentrating. This structured approach helps therapists meet medical necessity and compliance standards while providing thorough documentation of each session.
Main Functions of Progress Notes AI™
Session Documentation Guidance
ExampleThe AI guides the therapist through documenting a session using a specific format like SOAP. It prompts for details such as session type, time, active symptoms, and interventions used.
ScenarioDuring a telehealth session, the AI prompts the therapist to document the start and end time, the client's anxious mood, and the cognitive restructuring techniques used.
Symptom and Impairment Tracking
ExampleThe AI helps track active symptoms and impairments, ensuring ongoing treatment needs are clearly documented.
ScenarioIn a session, the client reports continued feelings of overwhelm and difficulty concentrating. The AI prompts the therapist to record these symptoms and consider them in the treatment plan.
Treatment Plan Progress and Recommendations
ExampleThe AI assists in documenting treatment plan progress and making recommendations for future sessions.
ScenarioAfter several sessions, the AI helps the therapist document progress, such as improvements in the client's mood, and recommends adjusting the therapeutic focus to address emerging symptoms.
Ideal Users of Progress Notes AI™
Licensed Therapists
Licensed therapists benefit from using Progress Notes AI™ by receiving structured guidance on documentation, ensuring compliance with medical necessity standards, and creating thorough session notes that capture all necessary details.
Therapy Clinics and Practices
Therapy clinics and practices can utilize Progress Notes AI™ to standardize documentation across all therapists, ensuring consistency and thoroughness in session notes, which can improve overall treatment quality and administrative efficiency.
Guidelines for Using Progress Notes AI™
Step 1
Visit aichatonline.org for a free trial without login, also no need for ChatGPT Plus.
Step 2
Select the desired note format (SOAP, DAP, BIRP, etc.) to match your clinical documentation needs.
Step 3
Input the session details, including type and time of session, active symptoms, observations, cognitive functioning, affect, mood, ADLs, sleep patterns, and medication adherence.
Step 4
Document the interventions used, treatment plan progress, recommendations, and any homework or goals set for the client.
Step 5
Review the generated progress note, make any necessary edits, and save or export the final document to your practice management system.
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Common Questions About Progress Notes AI™
What is Progress Notes AI™?
Progress Notes AI™ is a tool designed to help therapists create detailed and compliant progress notes by guiding them through various formats like SOAP, DAP, and BIRP, ensuring thorough documentation of sessions.
How does Progress Notes AI™ ensure compliance with documentation standards?
The tool prompts users to include necessary details such as session type and time, active symptoms, cognitive assessments, mood, interventions, and treatment plan progress, meeting medical necessity and documentation standards.
Can Progress Notes AI™ be used for telehealth sessions?
Yes, Progress Notes AI™ supports documentation for both telehealth and face-to-face sessions, ensuring accurate and comprehensive notes regardless of the session format.
What types of interventions can be documented using Progress Notes AI™?
Interventions like cognitive restructuring, DBT, behavioral management, motivational interviewing, EMDR, and more can be documented using Progress Notes AI™, providing a detailed record of therapeutic activities.
How does Progress Notes AI™ assist with treatment plan progress?
The tool allows therapists to document the continuation or modification of treatment plan goals, track progress, and make recommendations for future sessions, ensuring a structured and goal-oriented treatment process.