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Adding other documents, diagnoses, and treatment plans

Adding other documents, diagnoses, and treatment plans

Other documents, diagnosis and treatment plans, and Mental Status Exams are documentation that can be added to a client's file at any time without being tied to a specific date of service. There’s no limit to how many can be added.

In this guide, you’ll find steps to add, edit, share, and print the following:

Note: At this time, Mental Status Exams aren’t available to share with clients via the Client Portal.


Other documents

Note: Other documents are only available with the Essential and Plus plans. This feature isn’t available for Starter plan accounts.

In this section, we’ll cover:


Adding an other document to a client's file

To add an other document to a client's file: 

  • Navigate to the client’s Overview page
  • Click New > Other document

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  • Select the Other document template you want to add from the dropdown

Note: You can click Documentation history in the top right corner to view any past documentation for the client. For additional information, see Viewing documentation history.

  • Complete the other document

Tip: When completing your other documents, you can save time with snippets and macros. To learn how these features work, see Using snippets.

  • Assign the Date and time of document
    • This will determine where the other document appears on the client’s Overview page 
  • Check the box for Include diagnosis code on the printed document to include the diagnosis code on the PDF version of this other document

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  • Click Save

If you're on the Plus or Essential plan, you'll have access to our entire library of pre-built other document templates. For more, see Using our pre-built templates.

You can also follow the steps in Creating customized templates to create your own other document templates.


Viewing or editing an other document

You can find a client’s other documents on their Overview page. To quickly see all other documents you or another clinician have completed for a client:

  • Click All Items on the client’s Overview page
  • Select Other documents from the dropdown

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  • To edit an other document, click the Other document title
    • If the other document is unlocked, hover over the other document and click the Edit button

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  • To delete an unlocked other document from the client's Overview page, hover over the other document and click the trash can icon
  • To delete an unlocked other document while viewing it, click More > Delete

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Note: Only unlocked other documents can be deleted. For steps on unlocking other documents, see Amending a locked other document.


Signing and locking an other document

After you've completed an other document for a client, you can lock the other document and sign it with an e-signature by clicking Sign.

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If needed, you can edit the Provider Name and Credentials in the Sign and lock document modal. When ready, click Sign and lock.

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You'll then see your electronic signature under Signatures.

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If you’re under supervision, you can click Sign and share to send the other document to your supervisor for review. For more information, see Adding a Supervisor to review and sign notes.

Note: There currently isn't a way to customize this signature further.


Sharing an other document with a client for e-signature

After signing and locking an other document, you can share it with a client or contact so they can electronically sign it. To do this:

  • Navigate to the client's Overview page
  • Click the Other document
  • Select Share

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  • Review the information being sent and click Continue to Email

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  • Review the content of the email and choose Continue to Review > Share & Send Now
    • The email content can be edited manually, or you can customize the default content by following the instructions in Customizing email reminders

You can view the status of an other document that's been sent for signature under the Files tab on the client's Overview page.

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After the client signs the document, their signature will also be displayed below the provider’s in the Signatures section.

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Amending a locked other document

Other documents are important for creating a legal health record of your client encounters and for measuring client progress. If necessary, an Account Owner or clinician with access can unlock other documents to make amendments, corrections, or clarifications.

Note: See Team member roles and access levels to learn more about team member roles.

This feature should be used with care. You’ll need to implement some best practices to use it in a way that’s consistent with HIPAA requirements and professional ethics:

  • Being vigilant about maintaining the security and privacy of your SimplePractice account, such as using antivirus software, strong passwords for your accounts and your devices, maintaining a safe environment for storing your records, and taking other necessary precautions
    • Find more information on recommended practices on our Security page
  • Making sure you’re always logged in to your own account and never sharing accounts with others, including team members
  • Monitoring and auditing your Account Activity on a regular schedule to identify any unusual behavior immediately
  • Training your HIPAA workforce, including clinical and administrative staff, in accordance with the Privacy and Security Rules

While this feature is built in a HIPAA-compliant way, you and your fellow clinicians are ultimately responsible for safeguarding the information in your SimplePractice account.

For more information, please review these helpful resources:

To amend, correct, or clarify a locked other document

  • Navigate to the other document in question from the client's Overview page
  • Click Unlock

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  • Review the Notice of Data Integrity 
  • Enter the Reason for unlocking
  • Click Accept & Unlock

After the other document is unlocked, you’ll see an unlocked message beneath it.


Granting or revoking clinician access to unlock locked other documents

If you're the Account Owner or a practice manager, you can grant or revoke other clinicians' ability to unlock other documents they’ve added. To do this:

  • Navigate to Settings > Team > Team members
  • Select the name of the clinician you want to edit permissions for
  • Scroll to the Role info section
  • Click Edit
  • Select Continue
  • Toggle Unlock other documents on or off

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  • Click Continue
  • Select Save changes

To learn more, see Updating a team member’s role or access level.


Creating a custom ROI as an other document

If you'd like a Release of Information (ROI) form that can be customized on a client-by-client basis, you can create an other document for a client with our Release of Information template. This template will be available by default when you’re creating an other document.

Once you’ve customized and completed this document with the ROI template, you can sign, lock, then share it with the client through the Client Portal for e-signature.

Note: If the template doesn’t appear available when you create an other document, you can add it from our pre-built templates. For more information, see Using Release of Information (ROI) templates.


Printing or downloading an other document

To print an other document or download it as a PDF, hover over the Other document on the client’s Overview page and click the printer icon.

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Note: Unanswered questions won't appear on the printed version of an other document.

You can also print or download a locked other document by selecting it from the client’s Overview page, and then clicking the printer or download icon.

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Note: If the other document is unlocked, you can print it by clicking More > Print while viewing it.


Diagnosis and treatment plans

In this section, we’ll cover:


Adding a diagnosis and treatment plan to a client's chart

To add a diagnosis to a client's file:

  • Navigate to the client's Overview page
  • Click New > Diagnosis and treatment plan

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  • Select a diagnosis code
    • You can adjust the diagnosis description by typing in the Description text box
  • Click the plus icon to add multiple diagnoses if needed
  • Click Save

The first diagnosis you add to a client’s file will be applied to all of the appointments that client has, whether they took place before or after the date and time on that diagnosis code. For subsequent diagnoses, you can adjust the date and time to reflect the correct time. For more, see Editing, printing, or deleting a diagnosis and treatment plan.

Note: You can add and save a diagnosis without a treatment plan, or vice versa.

Once you've saved a diagnosis, you can use a custom treatment plan or create a Simple, Basic, Advanced, or Wiley treatment plan.

Note: To view all SimplePractice treatment plan templates, see Treatment plans. Wiley Treatment Planners are only available on our Essential and Plus subscriptions.

To add a treatment plan:

  • Use the dropdown under Select a treatment plan template to choose one of your existing treatment plan templates or one of the SimplePractice templates (Simple, Basic, Advanced, or Wiley)

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Tip: When adding a Simple or Basic treatment plan, you can save time with snippets and macros. To learn how these features work, see Using snippets.

  • Enter the treatment plan information
    • Click Documentation history in the top right corner to view any past documentation for the client. For additional information, see Viewing documentation history
  • Click Complete and Save

Note: The Date and time assigned to plan will default to the current date and time, and will only apply to appointments after that time. If you want to make sure a diagnosis shows up on previous super bills and notes, you can click the date and time to manually backdate it. 

If you’ve already created a treatment plan for a client, you can also build off a previous treatment plan to create the new one. To learn more, see Using a previous treatment plan to create a new treatment plan.


Editing, printing, or deleting a diagnosis and treatment plan

To edit, print, or delete a diagnosis and treatment plan:

  • Navigate to the client's Overview page
  • Hover over the Diagnosis and treatment plan and select from the following:
    • Edit to make changes
    • The printer icon to print
    • The trash can icon to delete

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Note: If the diagnosis and treatment plan has been locked, it’ll need to be unlocked before it can be edited or deleted.

You can also edit, print or delete a diagnosis and treatment plan by selecting it from the client’s Overview page. Click the pencil icon to edit the diagnosis, or select More for options to Print, Download, or Delete the diagnosis.

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Signing a diagnosis and treatment plan

You can sign and lock a client's diagnosis and treatment plan at any time. To do this:

  • Navigate to your client's Overview page
  • Click the Diagnosis and treatment plan you'd like to sign
  • Select Sign

After reviewing your name and credentials, click Sign and lock

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Once you sign a diagnosis and treatment plan, it’ll automatically be locked. To unlock it:

  • Navigate to your client's Overview page
  • Click the Diagnosis and treatment plan you'd like to unlock
  • Choose Unlock

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  • Enter the Reason for unlocking
  • Click Accept & Unlock

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Note: The ability to unlock treatment plans is based on team member permissions. To learn more, see Granting or revoking clinician access to unlock locked other documents.


Sharing a diagnosis and treatment plan with a client for e-signature

After signing and locking a diagnosis and treatment plan, you can share it with a client or contact so they can electronically sign it. To do this:

  • Navigate to the client's Overview page
  • Click the Diagnosis and treatment plan you'd like to share
  • Choose Share in the upper right corner

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  • Review the document being shared and click Continue to Email

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  • Review the content of the email and click Continue to Review > Share & Send Now

Using a previous treatment plan to create a new treatment plan

You can quickly create a new treatment plan by loading the client’s current treatment plan. This will allow you to update their treatment plan, while still retaining a copy of the original completed treatment plan.

To do this:

  • Navigate to the client's Overview page
  • Click New > Diagnosis and treatment plan
  • Select Load last plan
    • This option will only show if you have a treatment plan already stored for the client

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Note: To view the client’s current treatment plan, click Documentation history.

  • You'll then see the new treatment plan populate with content from the previous treatment plan, which you can edit
  • Click Save

You’ll see on the client’s Overview page that the new treatment plan and the original plan are both saved.


Setting up treatment plan reminders

Treatment plan reminders let you know when it's time to review a client's treatment plan. They’re optional, and can be set for a specific date, or set interval of time.

To set up or edit a treatment plan reminder:

  • Navigate to a client's Overview page
  • Select their most recent diagnosis and treatment plan 
  • Click the pencil icon
    • You may need to unlock the diagnosis and treatment plan first
  • Under Reminder to review plan, select the timeframe or date to receive the reminder

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  • Click Save, Update, or Update Treatment Plan

Important: If you want to update the client's treatment plan while still retaining a copy of the original treatment plan, you'll want to create a new diagnosis and treatment plan using the Load last plan option. For instructions on how to do this, see our section on Using a previous treatment plan to create a new treatment plan.


Mental Status Exams

In this section, we’ll cover:

Note: Unlike our other document types, Mental Status Exams are unable to be signed, locked and unlocked, or shared with clients for an e-signature.


Creating a new Mental Status Exam

To create a new Mental Status Exam:

  • Navigate to the client's Overview page
  • Click New > Mental status exam

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  • Select your responses for each field

Tip: When adding a Mental Status Exam, you can save time with snippets and macros. To learn how these features work, see Using snippets.

  • Adjust the Date and time, if needed

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  • Click Save Mental Status Exam 

Note: If you’re on the Essential or Plus plan, you can also create a custom progress note or other document with Mental Status Exam fields through the Template library. See Creating customized templates to learn more.


Editing, Printing, or deleting a Mental Status Exam

To edit or print a Mental Status Exam:

  • Navigate to the client's Overview page
  • Hover your cursor over the Mental Status Exam and click Edit or the printer icon

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To delete a Mental Status Exam:

  • Navigate to the client's Overview page 
  • Hover your cursor over the Mental Status Exam and click the trash can icon

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  • Click Delete now

Important: Once you delete a Mental Status Exam, this can’t be undone.

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