Assessments, diagnoses and treatment plans, and mental status exams are documentation that can be added to a client's file without being tied to a specific date of service. These can be added at any time, and there’s no limit to how many can be added.
Below, there are the steps to add, edit, print, use, and share the following:
Note: At this time, mental status exams aren’t available to share with clients via the Client Portal.
Assessments
Note: Assessments 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 assessment to a client's file
- 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 file
To add an assessment to a client's file:
- 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
- Check the box for Include diagnosis code on the printed document to include the diagnosis code on the PDF version of this assessment
- 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. To view a full list of our templates, see Template options in our Template Library.
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:
- Click All Items on the client’s Overview page
- Select Assessments from the dropdown
- To edit an assessment, click the Assessment title, or hover over the assessment and click the Edit button
- To delete an unlocked assessment from the client's Overview page, hover over the assessment and click the trash icon
- To permanently delete an 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.
If needed, you can edit the Provider Name and Credentials in the Sign and lock Assessment modal. When ready, click Sign & Lock.
You'll then see your electronic signature under Signatures.
If you’re under supervision, you can click Sign & Share to send the assessment 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 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
- Select Share
- 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 client signs the document, their signature will also be displayed next to the provider’s in the Signatures section.
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, and clinicians with access, to unlock assessments 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:
- 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:
- Summary of the HIPAA Security Rule
- Security 101 for Covered Entities
- CMS Resource about EHRs
- Fundamentals of the Legal Health Record and Designated Record Set
To amend, correct, or clarify a locked assessment:
- Navigate to the assessment in question from the client's Overview page
- Click Unlock
- Review the Notice of Data Integrity
- Enter the Reason for unlocking
- Click Accept & Unlock
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 added. To do so:
- Navigate to Settings > Team Members
- Select 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
- Click Update Team Member o 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
- If you don’t see the Release of Information template, you can add it from the Template Library
- 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 dropdown field
- Click Save
Clicking New > Assessment on 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 icon.
Note: Unanswered questions won't appear on the printed version of an assessment.
Diagnoses and treatment plans
In this section, we’ll cover:
- Adding a diagnosis and treatment plan to a client's file
- Editing, printing, or deleting a diagnosis and treatment plan
- Signing a diagnosis and treatment plan
- Sharing a diagnosis and 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 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
- Select a diagnosis code
- You can adjust the diagnosis description by clicking into the text box after choosing the diagnosis code, and typing the new description
- 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 timestamp on that diagnosis code. For subsequent diagnoses, you can adjust the timestamp to reflect the correct time.
Note: You can also 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.
Note: To view all SimplePractice treatment plan templates, see Treatment plans.
To add a treatment plan:
- Under Select a treatment plan template, use the dropdown to select one of your existing treatment plan templates or one of the SimplePractice templates (Simple, Basic, Advanced, or Wiley)
- To learn more about Wiley Treatment Planners, see Using Wiley Treatment Planners
- 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. If you want to have this diagnosis show up on superbills and previous notes, you can backdate the diagnosis and treatment plan.
If you’ve already created a treatment plan for a client, you can also use 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 treatment:
- Navigate to the client's Overview page
- Locate the Diagnosis and treatment plan that you'd like to edit or delete
- Hover over the Diagnosis and treatment plan and select from the following:
- Edit to make changes
- The printer icon to print
- 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
- After reviewing your name and credentials, click Sign & Lock
Once you sign a diagnosis and treatment plan, it's considered locked. To unlock it:
- Navigate to your client's Overview page
- Click the Diagnosis and treatment plan you'd like to unlock
- Choose Unlock
- Enter the Reason for unlocking
- Click Accept & Unlock
Note: The ability to unlock a treatment plan is based on team member permissions. To learn more, see Granting or revoking clinician access to unlock locked assessments (group practices only).
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
- Review the document being shared and click Continue to Email
- Review the content of the email and choose 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 previously 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 and treatment plan
- Click Load previous
- This option will only show 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
You can set up treatment plan reminders in your SimplePractice account. 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.
Note: 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 or edit a treatment plan reminder:
- Navigate to a client's Overview page
- 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
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
In this section, we’ll cover:
- Creating a new mental status exam
- Deleting a mental status exam
- Editing or printing a mental status exam
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
- Select your responses for each field
- Adjust the Date and time, if needed
- Click Save Mental Status Exam
Note: You can also create a custom assessment or progress note with mental status exam fields through the My Notes and Forms feature, which is available on the Essential and Plus plans. See Creating customized templates in My Notes and Forms to learn more.
Deleting a mental status exam
Important: Once you delete this document, this action can’t be undone.
- Navigate to the client's Overview page
- Hover your cursor over the mental status exam and click Delete
- Click Delete now
Editing or printing 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 printer icon
