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100% automated clinical documentation,
made for behavioral health
We complete ASAMs, biopsychosocials, and more—directly in your EMR.
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Biopsychosocial Long
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Biopsychosocial Long
Client appeared anxious upon arrival, fidgeting and avoiding eye contact. Discussed work-related panic attacks affecting performance and relationships. Client demonstrated good insight into triggers.
I. Presenting Problem
A. Presenting Problem and Goals for Attending
The client sought treatment because their drinking has increased over the last year, affecting their sleep, mood, and relationship. They also want to stop using cocaine on weekends. Additionally, the client is experiencing anxiety and panic-like episodes, particularly on Sunday nights. External motivators include their partner's concerns and the desire to maintain job stability, while internal motivation stems from feeling anxious and losing weekends due to substance use.
B. History of Presenting Problem
The client describes their family as "close but not very emotional." They characterize their parents as practical and private, stating, "We did not talk about feelings much. Holidays were predictable and calm." The family generally got along "mostly well," with some tension when the father worked long hours, but no violence. The client is closest to their younger sister, Maya, with whom they talk often.
3. Does the client have any siblings?
Yes
No
Simple Practice
Kipu
Alleva
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File
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32
12
21 Tuesday
9:15 PM
Calendar
Clients
Billing
Insurance
Analytics
Activity
Settings
Notifications
1
Tasks
Requests
Inquiries
Marketing
Recent
Search clients
Sep income
$100.00
Messages
Select a plan
Progress Note
Biopsychosocial Long
Load last note
Data started form
Biopsychosocial Long
Client appeared anxious upon arrival, fidgeting and avoiding eye contact. Discussed work-related panic attacks affecting performance and relationships. Client demonstrated good insight into triggers.
I. Presenting Problem
A. Presenting Problem and Goals for Attending
The client sought treatment because their drinking has increased over the last year, affecting their sleep, mood, and relationship. They also want to stop using cocaine on weekends. Additionally, the client is experiencing anxiety and panic-like episodes, particularly on Sunday nights. External motivators include their partner's concerns and the desire to maintain job stability, while internal motivation stems from feeling anxious and losing weekends due to substance use.
B. History of Presenting Problem
The client describes their family as "close but not very emotional." They characterize their parents as practical and private, stating, "We did not talk about feelings much. Holidays were predictable and calm." The family generally got along "mostly well," with some tension when the father worked long hours, but no violence. The client is closest to their younger sister, Maya, with whom they talk often.
3. Does the client have any siblings?
Yes
No
Simple Practice
Kipu
Alleva
Finder
File
Edit
View
Go
Window
Help
32
12
21 Tuesday
9:15 PM
Calendar
Clients
Billing
Insurance
Analytics
Activity
Settings
Notifications
1
Tasks
Requests
Inquiries
Marketing
Recent
Search clients
Sep income
$100.00
Messages
Select a plan
Progress Note
Biopsychosocial Long
Load last note
Data started form
Biopsychosocial Long
Client appeared anxious upon arrival, fidgeting and avoiding eye contact. Discussed work-related panic attacks affecting performance and relationships. Client demonstrated good insight into triggers.
I. Presenting Problem
A. Presenting Problem and Goals for Attending
The client sought treatment because their drinking has increased over the last year, affecting their sleep, mood, and relationship. They also want to stop using cocaine on weekends. Additionally, the client is experiencing anxiety and panic-like episodes, particularly on Sunday nights. External motivators include their partner's concerns and the desire to maintain job stability, while internal motivation stems from feeling anxious and losing weekends due to substance use.
B. History of Presenting Problem
The client describes their family as "close but not very emotional." They characterize their parents as practical and private, stating, "We did not talk about feelings much. Holidays were predictable and calm." The family generally got along "mostly well," with some tension when the father worked long hours, but no violence. The client is closest to their younger sister, Maya, with whom they talk often.
3. Does the client have any siblings?
Yes
No
Cutting admin time
Cutting admin time
Cutting admin time
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How it works
Our Chrome extension listens to clinical sessions and generates clinical documentation directly in your EMR
Fill out assessments in seconds
Complete intake and progress forms automatically so you can stay present with your clients instead of buried in paperwork.
Fill out assessments in seconds
Complete intake and progress forms automatically so you can stay present with your clients instead of buried in paperwork.
Fill out assessments in seconds
Complete intake and progress forms automatically so you can stay present with your clients instead of buried in paperwork.
100% compliant notes, every time
Generate documentation that’s audit-ready and meets all clinical standards—so you can chart with confidence.
100% compliant notes, every time
Generate documentation that’s audit-ready and meets all clinical standards—so you can chart with confidence.
100% compliant notes, every time
Generate documentation that’s audit-ready and meets all clinical standards—so you can chart with confidence.
30-Minute Setup
Quick onboarding gets you automating documentation same day.
30-Minute Setup
Quick onboarding gets you automating documentation same day.
30-Minute Setup
Quick onboarding gets you automating documentation same day.
Zero Training
Works with your existing workflow without changing any processes.
Zero Training
Works with your existing workflow without changing any processes.
Zero Training
Works with your existing workflow without changing any processes.
Stats
Stats
Stats
of behavioral health clinicians' time is spent on documentation.
We make that number
We make that number
Biopsychosocial Assessment
AI Auto-fill
Client's referral source
Case manager Sarah Jones
Reason that client is seeking care
I've been having panic attacks at work and it's affecting my relationships. I can't sleep and feel anxious all the time.
Does the client have any previous mental health diagnoses?
No
Yes
Who diagnosed it?
Dr. Smith
When?
March 2019
Where?
Community Health Center
SOAP Progress Note
AI Auto-fill
Subjective
Client reports increased anxiety and panic attacks at work over the past month. Sleep disturbances and difficulty concentrating. Denies suicidal ideation. Previous therapy helpful.
Objective
Alert and oriented x3. Anxious mood and affect. Speech rapid, thought process organized. Fair insight and judgment. Cooperative with treatment.
Assessment
Generalized Anxiety Disorder (F41.1). Client would benefit from cognitive behavioral therapy and stress management techniques. Consider medication evaluation.
Plan
Continue weekly individual therapy. Teach relaxation techniques. Assign anxiety monitoring worksheet. Referral to psychiatrist for medication evaluation. RTC in 1 week.
Time Drain
Clinicians spend 2-3 hours per day on documentation instead of direct patient care.
Time Drain
Clinicians spend 2-3 hours per day on documentation instead of direct patient care.
Time Drain
Clinicians spend 2-3 hours per day on documentation instead of direct patient care.
Clinician Burnout
Administrative burden is the leading cause of clinician burnout and turnover.
Clinician Burnout
Administrative burden is the leading cause of clinician burnout and turnover.
Clinician Burnout
Administrative burden is the leading cause of clinician burnout and turnover.
Revenue Loss
Poor documentation leads to denied claims and reduced reimbursements.
Revenue Loss
Poor documentation leads to denied claims and reduced reimbursements.
Revenue Loss
Poor documentation leads to denied claims and reduced reimbursements.
© 2024 Perspectives. All rights reserved. Built with care for healthcare professionals.
© 2024 Perspectives. All rights reserved. Built with care for healthcare professionals.
© 2024 Perspectives. All rights reserved. Built with care for healthcare professionals.