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:
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
- Viewing or editing an assessment
- Signing and locking an assessment
- Amending a locked assessment
- Granting or revoking clinician access to unlock locked assessments (group practices only)
- Printing or downloading an assessment
Adding an assessment to a client's chart
Here's how to add an assessment to a client's chart:
- Go to the client’s Overview page and click +Create New > Assessment.
- Select the Assessment template you want to add from the dropdown.
- Complete the Assessment.
- Assign a date and time to the Assessment. This will determine where the Assessment appears on the client’s Overview page.
- Click Save Assessment.
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 Overview page. To quickly see all assessments you or another clinician have completed for a client, select Assessments from the filter dropdown on the client’s Overview page.
To edit an assessment, you can click the Assessment title or hover over the assessment and click the Edit button that appears on the right.
To delete an unlocked assessment from the Overview page, click the trash icon. To delete a saved, unlocked assessment while viewing it, scroll to the bottom and click Delete to permanently delete the assessment.
Signing and locking an assessment
After you've completed an Assessment for a client, you can lock the Assessment and sign it with your e-signature by clicking Lock.
If you are under supervision, you can click Sign & Share with Supervisor to send the Assessment to your supervisor for review.
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. You can learn more here: Account Activity: Tracking changes and information access in your account.
- 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:
- Go to the assessment in question from the client's Overview page.
- Click Unlock next to the Locked and Signed e-signature at the bottom of the assessment.
- 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.
- After the assessment is unlocked, you’ll see an Unlocked message underneath the assessment.
Granting or revoking clinician access to unlock locked assessments (group practices only)
If you are the SimplePractice Account Owner, you can grant or revoke other clinicians' ability to unlock assessments they wrote.
- Go to My Account > Settings > Team Members and click the name of the clinician you want to grant access for.
- Scroll to the Permissions section, and check the Allow clinician to unlock Assessments checkbox to grant the clinician this access, or uncheck the checkbox to revoke this clinician's access.
- Click 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.
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
- Editing, printing, or deleting a diagnosis & treatment plan
- Loading a previous treatment plan to create a new treatment plan
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 +Create New > Diagnosis & Treatment Plan
- Select a diagnosis
- Click Save Diagnosis
- You're able to 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. Here's how:
- Click Basic, Advanced, or Wiley to create a treatment plan.
- Enter the treatment plan information.
- Click Complete and Save.
Note: The Date and 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 & treatment plan.
Tip: To learn more about using Wiley Treatment Planners, see this guide: Using Wiley Treatment Planners.
Editing, printing, or deleting a diagnosis & treatment plan
To edit, print, or delete a treatment, follow these steps:
- Go to the Client's Overview page.
- Find the Diagnosis & Treatment Plan that you would 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.
Loading a previous treatment plan to create a new treatment plan
The Diagnosis & Treatment Plan feature in SimplePractice lets you quickly create a new treatment plan by loading the previous treatment plan. Here’s how:
- Navigate to the Client's Overview page.
- Click +Create New > Diagnosis & Treatment Plan.
- If you have a previous treatment plan stored for this client, click Create from previous.
- Then you'll see the new treatment plan populated with the information from the previous plan. You may edit this information as necessary to reflect any new information.
- Click Save. This will take you back to the client's Overview page where you can see that the new treatment plan and the original plan are both saved and still accessible.
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
- Deleting a mental status exam
- Editing or printing a mental status exam
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 + Create New > Mental Status Exam
- Select your responses for each field and adjust the Date & Time if needed
- 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 on an appointment as 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