The clinical record
Notes, treatment plans, diagnoses and outcome measures, in a chart that opens when an inquiry books.
What it does
- Signed notes stay signed
- A correction goes in a dated addendum beside the note, never over it.
- Psychotherapy notes kept apart
- Only their author reads them, and no export includes them.
- Group notes checked
- A group note is checked for other members' names before it is signed.
- Chart opens on booking
- Someone who never books never gets a clinical record.
- Supervisor cosignatures
- Each cosignature has a due date, and supervision hours count against your board's schedule.
See everything it does
- Requests to see or amend the record, with deadlines
- When a client asks to see or amend their record, the request is kept with its deadline.
- 42 CFR Part 2 consent and notices
- A chart covered by 42 CFR Part 2 releases nothing without the client's recorded consent or a named exception. Each release carries the notice the regulation requires.
- A first treatment plan due by a session count
- A client's first treatment plan is due by a session your practice names, counted in sessions held, and supervisors see which are late.
- One signature for the whole plan
- A treatment plan is signed once, as one version. A change is a new draft that replaces it when signed.
- Objectives carried from one plan version to the next
- Each objective has a target date, and a revised plan is signed only once each objective is marked met, progressing, no progress or discontinued.
- The client's agreement to each plan version
- The client agrees to each version of the plan in session or from the portal, and a refusal is recorded too.
- Plan templates your practice writes
- Your practice keeps its own plan templates, and a clinician changes a template's words for the client before anything is saved.
- Plan fields your practice adds
- Your practice adds its own fields to the treatment plan, and a field marked as needed stops the signature, never a save.
- Deferred and referred-out needs
- A need marked deferred needs a reason, and one referred out names who it went to, before the plan is signed.
- Outcome targets on plan objectives
- An objective can name a PHQ-9 or GAD-7 target, and the plan reads the client's scored answers as its evidence.
- Plans printed whole or in part
- A plan prints at any stage, whole or chosen goals only, and a draft or replaced version says so on every page.
- A log of plan changes for supervisors
- Supervisors see a log of plan versions for the clients they oversee, without opening any plan.
- Deadlines on notes and questionnaires
- Your practice sets deadlines on notes and questionnaires, and only the signed note or the completed answer meets one.
- Deadlines on releases, forms and documents
- Releases, intake forms and filed documents such as insurance cards can carry deadlines, and a release is due again before it lapses.
- Deadlines assigned to a person or a role
- A deadline goes to the client's clinician, a role or a named person, and never to someone who cannot open the document.
- A deadline for one client
- A clinician can add a deadline for one client, and discharge stops it.
- Missed deadlines counted in the navigation
- Each overdue document shows how many times it was missed, and the navigation shows the count to the people who can act on it.
- Each clinician's unfinished work in one place
- Each clinician's home page lists their unsigned notes, cosignatures waiting, plans past review and deadlines due.
- A group's notes cosigned together
- A supervisor cosigns a group session's notes together, and one refused note stops only that note.
- A covering supervisor during approved leave
- A covering supervisor cosigns only during the supervisor of record's approved leave, and the note says who covered for whom.
- Authorization renewal warnings
- An authorization warns before it runs out at points your practice sets, counting the sessions already booked.
- Diagnosis codes checked against the day of service
- A diagnosis code is checked against the ICD-10-CM release in force on the day of service, not today's list.
- Documents sent under a signed release
- A signed letter or plan goes only to the address a current release names, and its link ends when the release is revoked.
- A client list you filter and arrange
- Clinicians filter the client list and choose its columns, and each filter appears only for clients they may see.
- Forms your practice writes and versions
- Your practice writes and changes its own forms, and each save is a new version, so a client's answers keep the question they answered.
Also: signed, versioned treatment plans, ICD-10-CM diagnosis lookup, PHQ-9 and GAD-7 scoring with trends, utilization review summaries, authorization and visit-limit tracking, drafted releases with a disclosure log and field-level encryption of clinical and billing text.
Priced by the size of your practice
A question first? Request a demo, or write to practicepillar@computingamerica.com