Tips for Documenting Patient Visits for Mental Health Professionals Using Mental Health EMR Software & Patient Portal

Mental health professionals diagnose a wide range of emotional, cognitive and behavioral disorders. In addition to diagnosing these disorders, mental health professionals must also evaluate the impact and severity of the condition on the individual’s ability to care for one’s self, to conduct daily activities, and to work.

With such a wide range of responsibilities, how can mental health professionals efficiently document patient encounters while fulfilling compliance regulations?

Consider using CRM (Customer Relationship Management) Software

First used for marketing purposes, CRM has now found its way into medical practices to improve the relationship between the physician and the patient by targeting patients who may benefit from appointment reminders or new services and products offered by the practice.

CRM software may also be used to manage the customer database. This software can be used to track how long a patient has been with the practice, dates of any transactions or exams, and any key conversation notes.

Mental Health Patient Portal

Self-assessment forms can serve as a powerful tool for collecting subjective data from patients. This method of documentation allows individuals to answer questions regarding their emotional and physical history in a timeline that best fits their needs, alleviating any stress that may come with recalling and discussing this history in person. This can all be done from a mental health specific patient portal. 1st Providers Choice currently offers a mental health specific patient portal with over 20 different self-assessment forms.

These forms will help the individual recognize potentially troublesome symptoms and can help the physician identify possible traumatic events that occurred in the patient’s life that may attribute to their condition. By using these self-assessment forms in a patient portal it can save the mental health provider significant time on initial intake and diagnosis. Data entered in the patient portal automatically flows into the initial exam notes, providing the physician with the patient’s main reason for their visit, the patient’s medical history and any current medications being taken.

Refer to the DSM-5 for Documenting Newly Implemented ICD-10 Codes

The DSM-5 is a guide for mental health professionals with a depth of criteria which helps providers arrive at the correct diagnosis for their patients. This manual also contains all corresponding ICD-10 codes for each diagnosis, which allows physicians to document more specifically the patient’s condition.

Organize Notes With IMS and Voice Recognition Software

IMS software for mental health offers unique templates for running a mental health practice as well as tools that analyze meaningful use requirements. In addition to IMS software, Mental Health EMR software with voice recognition makes note-taking for mental health professionals efficient by eliminating the need for transcription services. The software also offers secure features to keep confidential audio files safely stored.

At 1st Providers Choice, we are dedicated to helping healthcare providers efficiently run their practice and meet compliance regulations in order to strengthen the relationship and care of the patient. For more information on 1st Providers’ Choice Mental Health EMR software with voice recognition technologies, contact us online or call 480-782-1116.