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

• 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

Marriage and Family Therapy Progress Note

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

• "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

• 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

• 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