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 add, edit, print, use, and share the following:
Note: At this time, mental status exams are not available to share with clients via the Client Portal.
Assessments
Note: This feature is only available in Plus and Essential plan accounts. This is not available for Starter 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
- Sharing an assessment with a client for e-signature
- Amending a locked assessment
- Granting or revoking clinician access to unlock locked assessments (group practices only)
- Printing or downloading an assessment
- Creating a custom ROI assessment
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
- Select the Assessment 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 assessment
- Assign a Date & Time of Assessment
- This will determine where the assessment appears on the client’s Overview page
- Click Save
Note: If you're on the Plus or Essential 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.
To edit an assessment, 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 client's Overview page, click the trash icon. To permanently delete a saved, unlocked assessment while viewing it, click More > Delete.
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.
When the Sign & Lock Assessment modal appears, click Sign & Lock.
You'll then see your electronic signature at the bottom of the assessment under Signatures.
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.
Sharing an assessment with a client for e-signature
After signing and locking an assessment, 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 Assessment
- Choose Share in the upper right corner:
- Review the information being sent and click Continue to Email
- Review the content of the email and choose Continue to Review > Share & Send Now
You can view the status of an assessment that's been sent for signature under the Shared with Client section of the client's Overview page.
After the document's been signed, it will appear in your account with both your signature and theirs.
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
- To learn more, see: 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:
- Navigate to the assessment in question from the client's Overview page
- Click Unlock
- 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 beneath it
Granting or revoking clinician access to unlock locked assessments (group practices only)
If you're the 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 edit permissions 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
- Select Update Team Member when you're done to save your changes
Tip: Practice Managers can also adjust clinician permissions.
Creating a custom ROI assessment
If you'd like a Release of Information (ROI) form that can be customized on a client-by-client basis, you can create a shareable template that a client or contact can electronically sign rather than using the existing intake form. To do this:
- Navigate to Settings > Notes and Forms > My Notes and Forms
- Locate the Release of Information template under Intake Forms
- Click the Duplicate icon to create a Release of Information Copy under the original template
- Click the ROI copy
- Rename the copy, edit the content as needed, and select for Assessments in the drop-down field
- Click Save
Clicking New > Assessment in the client's Overview page will now allow you to create a customized, client-specific Release of Information. Once completed, signed, and locked, it can be shared with the client through the Client Portal for e-signature.
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.
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
- Editing, printing, or deleting a diagnosis & treatment plan
- Signing a diagnosis & treatment plan
- Sharing a diagnosis & treatment plan with a client for e-signature
- Using a previous treatment plan to create a new treatment plan
- Setting up treatment plan reminders
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
- Click New > Diagnosis & Treatment Plan
- Select a diagnosis code
- Click Save Diagnosis
Please note:
- You can 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 timestamp 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 use a custom treatment plan or create a Simple, Basic, Advanced, or Wiley treatment plan.
To use a custom treatment plan:
- Under My notes and forms, select a treatment plan template
- 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: To view SimplePractice treatment plan templates, see our Template Library.
To create a treatment plan, select Simple, Basic, Advanced, or Wiley from the Select a treatment plan template dropdown.
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
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
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
- Enter the reason for unlocking the Diagnosis & Treatment plan, and click Accept & Unlock
Sharing a diagnosis & 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 & Treatment Plan you'd like to share
- Choose Share in the upper right corner:
- Review the document being shared and click Continue to Email
- Review the content of the email and choose Continue to Review > Share & Send Now
Note: This feature is part of a phased rollout and is not yet available for all practices. If you don’t yet have access to this feature but would like it enabled in your account, please reach out to our Customer Success team for assistance.
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
- Click Load previous
- This option will only populate if you have a previous treatment plan stored for this client
- 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
- Under 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 Load 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
- 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 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 Plus and Essential plans. However, a custom template can only be used as an assessment or a progress note. See Creating customized templates in My Notes and Forms 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
