Long gone are the days of mental health professionals performing a counseling session, and then writing out the consult or the progress notes of the encounter. Also gone was the next iterations of this, with consults dictated into phone systems, or worse onto microcassette based dictation recorders for transcription. Also gone, is the version is the next step of manually typing these notes out in free text.
The commonality of all of these solutions is that we ended up with piles of poorly organized (or even completely unorganized) data. Rather, data needs to be structured, and easily accessible, which is why mental practices of all shapes and sizes have turned to a software based therapy notes solution.
Let’s take a look at some of the many benefits.
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These days, any therapy notes solution is going to be cloud based. The benefit of this is that the records can then be accessed from anywhere, unlike having client charts locked in the office in a filing cabinet.
With a cloud based architecture, this then allows the records to be viewed and worked with any internet connection. This obviously starts with the office, but then also records can be completed at home after hours to catch up without having to stay late at work.
Also, when on call, the records can be available on a smartphone via the appropriate app, allowing mobile access to the information as well. Finally, access to records can also be provided to a consultant, or even to a covering therapist for on call. This allows instant access to patient charts, in a privacy compliant method, in ways that would be impossible with traditional (and now increasingly outdated), paper charts.
Another benefit of cloud based architecture is the ability to store charts in a redundant fashion. This means that no patient’s chart will ever be permanently lost, or unable to be located. Rather, the info in the chart is all backed up to the cloud, and not locally just on a single hard drive, at risk for failure.
This means that not only is the data more accessible, but also it can be more redundant. In many cases, these therapy notes software solutions do not run their own servers, but use them from major providers like Amazon Web Services, Microsoft or Google. In turn, these major providers have built in high levels of redundancy so that the data is on multiple drives, in multiple locations, so in case any data center goes offline for whatever reason, such as a hurricane, the integrity of the data is preserved.
The gain in efficiency for the end user is that documentation and other essential data is not at any real risk to be lost.
Speech to text
In most cases, mental health professionals are not professional typists. The average typing speed for US adults is not particularly fast, at just over 40 words per minute. This can make getting through multiple notes a daunting task to fulfill the more detailed documentation requirements both from a liability standpoint, and also for billing, especially at the higher (and better reimbursing) codes.
Rather than struggling with the typing, far better to dictate, which most therapists will be faster at. Many dictation software solutions have a speech-to-text feature, that can take the voice, and then process it into text. Unlike sending it out for transcription, which can be expensive as you pay by the word, this is not only less expensive, but it is also faster as it is done in real time. Furthermore, the therapist can also review the text as it is being produced, and then take the opportunity to correct it, in real time, unlike having to wait to receive back the transcription days later, making this not only a far more efficient process, but also more accurate as the patient encounter is immediate.
For even better efficiency, the cutting edge of this is applying AI to the note writing process. In this variant, the therapy session gets audio recorded, and speech to text gets applied for an initial step. Then the AI goes to work populating the fields of a therapy note, that then just needs a final review by the therapist to fine tune the documentation.
The advantage of therapy notes software is to keep all the documents unified in a central location. A challenge is that there somehow ends up being the occasional paper intake form that needs to be signed, or paperwork that a patient brings, such as from a discharge from another facility, that needs to be collected, and integrated into the medical record.
Thankfully, you can put the 3-hole punch away. With a cost effective flatbed scanner, or a space saving, and more efficient sheet fed scanner, these documents can be quickly converted into digital images. From there, they can then be attached to the patient’s electronic chart, and categorized further turning them into digital information. It also makes them easier to find, rather than leafing through piles of paper.
Many mental health practices have expanded beyond the traditional office, and now offer remote sessions, better known as telehealth. Counseling and therapy sessions are particularly amenable to this approach.
In fact, with the right therapy note platform, it can streamline the telehealth process. This includes good integration with the patient’s medical record, making it a snap to document the visit. This also includes the platform to conduct the session, as it needs to be capable of both audio and video, and also needs to be encrypted so that it is HIPAA compliant. While there are independent platforms available, it is preferred to have a single unified platform for the telehealth and also the patient notes all together to maximize the efficiency.
While documentation requirements continue to increase, a powerful therapy notes program is an essential tool to push back with. This will increase the efficiency of not only the workflow of the therapist, but also benefits the entire practice.
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Jonas P. DeMuro is a freelance reviewer covering wireless networking hardware.