Best therapy notes software

Best therapy notes software refers to the various types of documentation that therapists maintain in the client record through a software program. Therapists in private practice must maintain accurate and timely client records.

Some of these notes include:

• Intake forms
• Progress notes
• Assessments, evaluations, and tests
• Treatment plans
• Discharge summaries
• Utilizing the best therapy notes software program can help to streamline your practice as opposed to using paper charts.

Therapy notes software can help your practice: 

• Run more efficiently
• Remain current with the client’s therapy notes 
• Eliminate unnecessary tasks such as filing and mailing out forms
• Remain compliant with requirements for insurance, licensure, and ethics boards

Benefits of using the best therapy notes software

Most electronic health record programs (EHRs) contain therapy notes software. The software is an electronic version of handwritten paper notes, forms, assessments, and other documentation. The best therapy notes software programs allow users to use a computer, tablet, or smartphone to enter data in the client’s medical record. 

The best therapy notes software can also improve the efficiency of your practice and streamline processes for you.

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Therapy notes software can support your practice through:

• Eliminating the need for endless filing of paperwork
• Allowing for easier reading of documentation (no illegible handwriting)
• Improving compliance with documentation standards by creating necessary components on forms (ex: dates, signatures, diagnoses, times of sessions)
• Integrating progress notes with treatment planning software such as the Wiley Practice Planner
• Securing and encrypting storage of therapy notes
• Obtaining electronic signatures from providers and clients 

Features to consider for the best therapy notes software

The best therapy notes software programs offer a wide array of features and benefits. Some of the features may come as a standard component of the software included in the monthly subscription. Some features may be upgrades or add-on features.

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Some of the common features of therapy notes software include:

Standard templates: Many of the best therapy notes software programs offer templates for forms, notes, and assessment tools. With the standard templates, you simply log onto your program and begin using the templates.

Templates might include:

• Intake forms 
• Progress notes 
• Initial assessments
• Treatment plans
• Discharge summaries

The best therapy notes software might also include standard templates for different types of progress notes:

• Individual therapy
• Group therapy
• Couples work
• Family therapy

Customizable templates: With customizable templates, you can create forms and documents that suit your practice's needs. For example, you can create an assessment with the specific questions needed for your niche or a progress note that includes the information you want in your notes. 

Secure storage: A therapy notes software program should provide you with HIPAA-level secure storage for your client record. Each user should have private and secure access to the program. The company should also offer a Business Associate Agreement (BAA) for you. 

Simplified documentation processes: The best therapy notes software program can make it easier and less stressful to create and maintain your treatment-related documentation.

Software can offer features such as:

• Integration of DSM and ICD diagnostic codes into notes, assessments, treatment plans, etc.

• Electronic signatures

• Supervisory reviews and co-signatures 

• Tracking client progress on notes and treatment plans

• Integration with Wiley Practice Planners to simplify treatment planning and progress note writing

• Drop down menus 

• Checkboxes

• Integration with note-taking apps 

• Transcription of handwritten electronic notes (using a stylus) and input of the notes directly into the therapy notes software

• Ability to review the client’s history while concurrently writing the current note

• Easily look up and integrate correct CPT codes into the progress note

• A mobile app that allows you to create, enter, and upload documentation

Easily share therapy notes: Therapy notes software should simplify the process of sharing documentation with others within the practice as well as sending documentation outside of the practice. 

Within the office, approved staff and providers can have secured access to the software which would allow access to the client’s medical records. Administrative staff can access the therapy notes when appropriate and necessary. Other clinicians on the treatment team can review therapy notes from another provider. Or, in a group practice, if the client transfers from one therapist to another, the new therapist can easily access the client’s history. 

When an outside provider or organization requests records, therapy notes software can simplify sharing the requested documentation. Some of the best therapy notes software offer the features of branding the documentation with personal brand information as well as contact information for the practice. Some offer the feature of downloading all the progress notes into one pdf document with a specified date range of services. 

How to select the best therapy notes software for your private practice

With all of the potential features and competitor vendors, selecting the best software for your practice may seem like an overwhelming process. It is important to consider the features that would help you most in your practice.

When comparing features, you might want to think about the specifics of your practice such as:

• Are you a solo practitioner or a group practice?

• Do you have plans to expand your practice?

• Do you offer specialized services that would impact what features you would like to have?

• Do you have a telehealth practice, in-person practice, or hybrid?

• Do you take insurance or provide superbills for out-of-network billing?

Based on your current practice and the vision for your practice, you may need certain features of your therapy notes software program in a monthly package. For example, a group practice would likely serve more clients than a solo practice. A group practice would need a monthly package that allows for greater caseloads. A group practice would also need a package that allows access to more than one clinician. 

It is also important to work within your budget. Most software programs designed for counseling practices offer a monthly subscription package. It gives you the freedom to upgrade levels as you grow the practice or decide to downgrade. 

The decision to utilize a therapy notes software program can eliminate unnecessary tasks from your private practice to-do list. You can spend less time collecting, writing, and maintaining necessary documentation related to your client’s record. Taking the time to compare different programs, engage in a demo with the sales representative, and try them out for the free trial period can help you to make a more informed decision on which therapy notes software program to choose for your practice.