Note templates in an EHR usually means that you don’t have to create a note from scratch, but can rather add to a pre-existing template that covers the basic structure of a client assessment. It’s good to remember that while these templates, also known as canned notes, make a lot of sense in general medicine, the world of mental & behavioral health is often much more subtle, both in assessment and diagnosis. Considering these nuances, should your EHR offer canned notes for mental health?
A medical doctor will often run diagnostic tests that provide concrete diagnoses, based on outcome data, whereas a mental health professional may need more than one meeting with a client to assess & determine diagnosis. Behavioral health clients may be experiencing more than one condition, which can affect your observation and diagnosis; even with scored testing, more in-depth notes may be required.
This isn’t to say that templates can’t be used in mental and behavioral health; in fact, canned notes for mental health can be an invaluable time-saving benefit to your agency. The key is finding the right templates for your specialties or being able to create & customize your own. Creating your own note and treatment plan templates allows you to truly save time, by building documents that capture your treatment methods.
You should also be able to customize your templates so that each note captures the specific individual needs of your agency’s clients, with all the nuances that mental health charting can include. Perhaps part of the note is canned, but the ability to add the customization needed for medical necessity – to support the CPT code and therefore reimbursement – is a must.
If you’re shopping for an EHR, ask potential vendors to demonstrate the format of their notes. Ask about templates: if you can create them, how difficult it is to do so; and how can these templates be edited or tweaked as you use them?
You should always request a no-strings-attached 30 to 90 minute demo of the systems you are seriously considering and see the program in action, with the opportunity to ask questions throughout. Be sure that notes and templates are included in these demos, as charting is obviously a vital portion of behavioral health treatment.
Click here to register for a complimentary one-hour demo of PIMSY mental health EHR. We’d love to show you how PIMSY can: save time; minimize redundancy; enhance productivity; and improve profitability for your agency.
Leigh-Ann Renz is the Marketing & Business Development Director of PIMSY EHR. For more information about electronic solutions for your practice, check out Mental Health EHR.