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Adding assessments, diagnoses, and treatment plans

Adding assessments, diagnoses, and treatment plans

In SimplePractice, assessments, diagnoses and treatment plans, and mental status exams are documentation that can be added to a client's chart without being tied to a specific date of service. These can be added at any time, and there's no limit to the number of these items you can add. 

Below are the steps to adding, editing, printing, and using the following: 


Assessments

Note: This feature is only available in Professional Plan accounts. This is not available for Essential Plan accounts.

This section covers how to use assessments in your account. You'll find steps on the following: 


Adding an assessment to a client's chart

Here's how to add an assessment to a client's chart: 

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

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  • Select the Assessment template you want to add from the dropdown

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  • Complete the assessment
  • Assign a Date & Time of Assessment
    • This will determine where the assessment appears on the client’s Overview page 

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  • Click Save

Note: If you're on the Professional Plan, you'll have access to our entire Template Library of pre-built assessment templates.


Viewing or editing an assessment

You can find a client’s assessments on their client Overview page. To quickly see all assessments you or another clinician have completed for a client, click All Items and select Assessments from the filter dropdown on the client’s Overview page.

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To edit an assessment, click the Assessment title, or hover over the assessment and click the Edit button that appears on the right.

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To delete an unlocked assessment from the client's Overview page, click the trash icon. To permanently delete a saved, unlocked assessment while viewing it, click More > Delete.

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Signing and locking an assessment

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

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When the Sign & Lock Assessment modal appears, click Sign & Lock.

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You'll then see your electronic signature at the bottom of the assessment under Provider Signature.

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If you are under supervision, you can click Sign & Share to send the assessment to your supervisor for review.

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


Amending a locked assessment

Assessments are important for creating a legal health record of your client encounters and for measuring client progress. The Unlock Assessments feature allows you, the Account Owner, to unlock your or a colleague’s assessments to make amendments, corrections, or clarifications. 

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

  • Be vigilant about maintaining the security and privacy of your SimplePractice account. This means using antivirus software, using strong passwords for your accounts and your devices, maintaining a safe environment for storing your records, and taking other precautions you deem necessary
    • Find more information on recommended practices by reviewing our Security page 
  • Make sure you’re always logged in to your own account. Never share accounts or login credentials with others
  • Any time the Unlock feature is used, a new entry will be logged in your Account Activity
  • Monitor and audit your Account Activity on a regular schedule to identify any unusual behavior right away
  • Train 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:

Here's how to amend, correct, or clarify a locked assessment:

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

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  • Read through the Notice of Data Integrity and enter the Reason for unlocking to document why you unlocked the assessment
  • Click Accept & Unlock to unlock the assessment and make the necessary corrections

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  • After the assessment is unlocked, you’ll see an unlocked message beneath it

Granting or revoking clinician access to unlock locked assessments (group practices only)

If you're the SimplePractice Account Owner, you can grant or revoke other clinicians' ability to unlock assessments they wrote.

  • Navigate to Settings > Team Members and click the name of the clinician you want to grant access for
  • Scroll to the Permissions section
  • Check the box next to Allow clinician to unlock Assessments to grant the clinician this access, or uncheck the checkbox to revoke this clinician's access

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  • Select Update Team Member when you're done to save your changes. 

Printing or downloading an assessment

To print an assessment or download it as a PDF, hover over the Assessment on the client’s Overview page and click the printer-shaped print icon.

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


Diagnoses & treatment plans

This section covers how to use diagnoses and treatment plans in your account. You'll find steps on the following: 


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

Here's how to add a diagnosis to a client's chart:

  • Navigate to the client's Overview page and click New > Diagnosis & Treatment Plan 

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  • Select a diagnosis code
  • Click Save Diagnosis

Please note: 

  • You're able to adjust the diagnosis description by clicking into the text box after choosing the ICD-10 code, typing the new description, and clicking Save Diagnosis
  • You can add multiple diagnoses for your client. To do so, click the plus icon next to the drop-down menu
  • The first diagnosis you add to a client’s profile will be applied to all of the appointments that client has whether they took place before or after the time stamp on that diagnosis code. For subsequent diagnoses, you can adjust the timestamp to reflect the correct time
  • You can add and save a diagnosis without a treatment plan

Once you've saved a diagnosis, you can create a Basic, Advanced, or Wiley treatment plan. To do this:

  • Click Basic, Advanced, or Wiley to create a treatment plan

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  • Enter the treatment plan information
  • Click Complete and Save

Note: The Date & Time Assigned will default to the current date and time time. If you want to have this diagnosis show up on superbills and previous notes, you can backdate the diagnosis and treatment plan. 

Tip: To learn more about using Wiley Treatment Planners, see: Using Wiley Treatment Planners.


Editing, printing, or deleting a diagnosis & treatment plan

To edit, print, or delete a treatment, follow these steps:

  • Navigate to the client's Overview page
  • Find the Diagnosis & Treatment Plan that you'd like to edit or delete
  • Hover over the Diagnosis & Treatment Plan and select Edit to make changes, the printer icon to print, or the trash icon to delete

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Signing a diagnosis and treatment plan

You have the ability to lock and sign a client's diagnosis and treatment plan at any time. To do this:

  • Navigate to your client's Overview page
  • Click the Diagnosis & Treatment Plan you'd like to sign
  • Select Sign, and you'll see a preview of how your name and signature will appear
  • Once you've reviewed your name and credentials, click Sign & Lock

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Once you sign a diagnosis and treatment plan, it's considered locked. If you need to unlock it, follow these steps:

  • Navigate to your client's Overview page
  • Click the Diagnosis & Treatment Plan you'd like to unlock
  • Choose Unlock

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  • Enter the reason for unlocking the Diagnosis & Treatment plan, and click Accept & Unlock

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Using a previous treatment plan to create a new treatment plan

The diagnosis and treatment plan feature in SimplePractice lets you quickly create a new treatment plan by loading the previous completed 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 & Treatment Plan
  • Choose Create from previous
    • This option will only populate if you have a previous treatment plan stored for this client

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  • You'll then see the new treatment plan populated with the information from the previous plan, which you can edit as needed
  • Click Save to go back to the client's Overview page, where you'll see that the new treatment plan and the original plan are both saved and still accessible

Setting up treatment plan reminders

Set up treatment plan reminders in your SimplePractice account and never miss a deadline for updating a client's treatment plan again. This optional feature allows you to set a reminder for a specific date, or for a set interval of time to let you know when it's time to review a client's treatment plan.

By default, any treatment plans added after 6/16/2020 will have a reminder set to 90 days after the date assigned to a treatment plan. 

To set up a treatment plan reminder for a client's existing treatment plan, or to change the timeframe for the reminder, simply:

  • Open their most recent treatment plan and scroll to the bottom of the page

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  • Under Set Reminder to Review Plan, select the timeframe or date that works best for your practice's requirements to receive the reminder
  • Click Update to save these changes

Note: Under Set Reminder to Review Plan, you also have the option to select None if you do not wish to receive a reminder to review a 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 Create from previous function. 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

This section covers how to use mental status exams (MSE) in your account. You'll find steps on the following: 


Creating a new mental status exam

To create a new mental status exam (MSE), follow these steps:

  • Navigate to the client's Overview page 
  • Click New > Mental Status Exam 

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  • Select your responses for each field and adjust the Date & Time if needed

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  • Click Save Mental Status Exam 

Note: You can create a custom MSE template through the My Notes and Forms feature available on the Professional Plan. However, a custom template can only be used as an assessment or a progress note. See My Notes and Forms: Creating customized client intake and progress note templates to learn more. 


Deleting a mental status exam

  • Navigate to the client's Overview page 
  • Hover your cursor over the MSE and click Delete
  • Click Delete now

Note: Once you delete this document, this action cannot be undone.


Editing or printing a mental status exam

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

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