The PsyPack Blog

Precision in Mental Health: The Impact of Measurement-Based Care (MBC)

Measurement-Based Care (MBC) stands as a pivotal approach in mental health, aiming for enhanced precision and consistency in disease assessment, tracking, and treatment to achieve optimal outcomes. According to , MBC involves the systematic use of symptom rating scales to guide clinical decision-making, seeking to optimize accuracy and efficiency in symptom assessment.Clinical Actionability and Symptom Rating ScalesFor symptom rating scale data to be clinically actionable, it must be current, accurate, interpretable, and readily available during clinical encounters. Outdated symptom severity data, outside the context of the clinical encounter, lacks clinical actionability and is not considered effective MBC. The interpretability of symptom rating scale scores is crucial, with changes categorized to facilitate treatment guidelines and medication prescribing algorithms.MBC and Depression Treatment GuidelinesDepression treatment guidelines recommend systematic reevaluation of symptoms at specified intervals. MBC greatly facilitates adherence to guidelines and algorithms by operationalizing and quantifying treatment responses. This approach supports the treat-to-target philosophy, emphasizing the revision of treatment plans until remission is achieved.Residual Symptoms and Relapse PreventionMBC plays a vital role in detecting residual symptoms, prompting clinicians to consider intensifying the treatment plan until complete remission. Residual symptoms, although not meeting diagnostic criteria, are linked to an increased risk of relapse. MBC aligns with collaborative care models, where self-reported depression severity scores are shared among care providers for team-based care.Enhanced Therapeutic Relationships and Patient Empowerment:MBC contributes to more favorable patient outcomes by fostering enhanced and facilitating timely revisions of treatment plans. Patients regularly completing self-reported rating scales become more knowledgeable about their disorders, attuned to symptoms, and better equipped to self-manage their illness. Standardized symptom rating scales empower patients by involving them in clinical decision-making and validating their experiences.Clinical Actionability and SustainabilityFor MBC to be effective and sustainable, symptom severity feedback must be perceived as clinically actionable. The instruments used should be reliable and sensitive to change, ensuring consistent and meaningful measurements. Patient-reported outcomes serve as a starting point in evaluating the clinical effectiveness of current treatments.ConclusionIn conclusion, MBC emerges as a transformative approach in mental health, not as a replacement for clinical judgment but as a tool to optimize the accuracy of assessments. By focusing on clinical actionability, interpretability, and sustainability, MBC stands as a powerful ally in the journey toward optimal mental health outcomes.
Team PsyPack
Team PsyPack
Fri Dec 15 2023

APA Recommended Adult Rating Scales

In the evolving landscape of mental health care, Measurement-Based Care (MBC) stands as a crucial tool for optimizing treatment outcomes. The American Psychiatric Association (APA) emphasizes the significance of routine MBC, backed by evidence of improved quality of care and patient-centered outcomes. This blog explores the recent recommended Adult Rating Scales.In conclusion, selecting the right measure is pivotal for successful MBC implementation. The table serves as a comprehensive guide, but the journey doesn’t end here. Most of these assessments are conveniently available on PsyPack, providing clinicians with a user-friendly platform to seamlessly integrate these tools into their practice. Empower your mental health practice with PsyPack and stay at the forefront of delivering patient-centered care.
Team PsyPack
Team PsyPack
Fri Dec 15 2023

Sustainable Reimbursement: A Guide to CPT Codes in Mental Health

Introduction: Navigating Reimbursement with CPT Codes in Mental Health CareIn the dynamic landscape of mental health care, the widespread adoption of Measurement-Based Care (MBC) is intrinsically tied to sustainable reimbursement channels. Currently, clinicians navigate two primary pathways for reimbursement: the direct billing codes route and the transformative realm of value-based contracting with payers, all anchored by the essential . This blog delves into these avenues, unraveling the opportunities they present for mental health practitioners to not only thrive but reshape the future of clinical practice.The Essential Role of CPT Codes: Billing for Mental Health Screening and Follow-Up AssessmentsIn the realm of Measurement-Based Care (MBC), understanding the coding landscape is pivotal for clinicians seeking reimbursement. The Common Procedural Terminology (CPT®) codes take center stage in this domain. The following codes serve as a compass for billing mental health screening and follow-up assessments. Each code is accompanied by a description and key notes on billing and utilization.However, it’s crucial to note that coding stipulations can vary by payer and region. To ensure accurate navigation through this coding maze, every physician is encouraged to consult with their health system, payer, or local authority for specific details. Let’s delve into the codes that form the backbone of CPT Code-based reimbursement for MBC.Beyond Direct Billing: Unlocking Value-Based Opportunities with CPT CodesWhile direct billing for Measurement-Based Care (MBC) services is a common avenue, clinicians can explore additional opportunities through value-based payment arrangements with payers. These arrangements may operate at both the health system and individual clinician levels, ushering in a new era of reimbursement dynamics, all anchored by the essential CPT Codes.In structures like Accountable Care Organizations (ACOs) or pay-for-performance arrangements, mental health screening and MBC may form integral components of the contract, driven by specific CPT Code benchmarks. The administration of evidence-based instruments may not directly translate into reimbursement, but consistent performance in MBC processes could indirectly secure financing through capitation or incentive payments, guided by CPT Code stipulations.At the individual clinician level, a rising trend among payers involves implementing financial strategies to incentivize MBC with evidence-based instruments, often tied to specific CPT Code targets. Payers may offer enhanced reimbursement for mental health visits when clinicians commit to using MBC and treatment targeting specific benchmarks. These arrangements typically carry upside risk only, meaning clinicians gain reimbursement for MBC use, without financial losses if patients don’t reach outcome benchmarks within a defined period, all under the umbrella of CPT Codes.While some payers directly offer such arrangements to their in-network clinicians, others leverage third-party technology services to define clear outcome benchmarks, implement enhanced reimbursement, and broadly incentivize MBC, framed by the guidance of CPT Codes.Unlocking Enhanced Value with PsyPack in the MBC JourneyAs clinicians navigate the intricate landscape of Measurement-Based Care (MBC) and CPT Codes, a powerful ally emerges in the form of . This innovative tool seamlessly integrates with MBC processes, offering features that extend beyond conventional practice. PsyPack boasts an impressive repertoire of about , including well-known assessments like , , , , , , and .PsyPack goes beyond mere test availability. It transforms the MBC experience with online administration, automatic scoring, and comprehensive reporting. Clinicians can leverage PsyPack to streamline their assessment processes, saving valuable time and ensuring accuracy in scoring. The platform’s tracking capabilities facilitate a seamless journey in monitoring treatment progress over time.In the realm of value-based care, PsyPack becomes a strategic partner, facilitating a comprehensive understanding of the practice’s performance. By harnessing the aggregate data, clinicians can uncover patterns, identify areas for improvement, and showcase the efficacy of MBC in achieving clinical outcomes. This holistic view not only aligns with value-based care principles but positions the practice for success in an evolving healthcare landscape.As you navigate the complexities of MBC and reimbursement strategies, consider as more than a tool—it’s a catalyst for elevating the standard of mental health care.
Team PsyPack
Team PsyPack
Fri Nov 10 2023

Unlocking the Power of Measurement-Based Care (MBC) in Mental Health

In the world of mental health, where clinicians work diligently to support their clients, a transformative approach is emerging. Traditionally, diagnosis and assessment relied heavily on clinician expertise and client-reported symptoms. However, there’s a powerful shift happening – structured symptom measurement, often facilitated by tools like the PHQ-9 and GAD-7 scales, is redefining mental health care. is akin to monitoring blood pressure for hypertension or regularly checking blood sugar levels for diabetes management – it’s a fundamental change in approach. The American Psychiatric Association (APA) recognizes this shift and recommends the integration of quantitative measures in psychiatric evaluations.The compelling part? Research shows that patients undergoing experience significantly improved mental health outcomes. In fact, this can lead to a remarkable increase in remission rates.But is more than just data collection. It strengthens the connection between clinicians and clients, enabling more precise interventions and continuous progress tracking. It’s not just about individual care; it’s a tool for enhancing care quality at all levels, from individual treatment plans to entire healthcare systems, utilizing established symptom rating scales.However, despite its potential, is not yet a standard practice in routine mental health care. The challenges vary, from time constraints to clinician skepticism and the need for system adjustments. Yet, when you consider the compelling evidence, offers a transformation that’s hard to ignore. It’s not merely about elevating clinical care; it also lays the groundwork for measuring care quality, which is crucial for health plan accreditation and value-based reimbursement.In essence, isn’t just about improving symptoms and clinician performance; it’s a gateway to a new era in mental health care. So why not embrace this transformative path?Why Measurement-Based Care?MBC’s Impact on Patient Engagement and Adherence is not just a buzzword in mental health; it’s a game-changer. Research suggests that it enhances patient engagement and overall treatment outcomes. How? By introducing routine symptom monitoring, ensures timely feedback and empowers clinicians to better understand their patients’ needs. This paves the way for more personalized care and improved treatment outcomes.The magic of doesn’t stop there. It’s also a catalyst for improved communication, shared decision-making, and a stronger physician-patient alliance. This is the kind of alliance that matters, and it’s a critical predictor of treatment adherence and engagement.Furthermore, , when integrated with symptom rating scales, provides patients with a common language to express their symptoms. This not only helps them better understand their condition but also reduces the stigma surrounding mental health disorders. The use of standard scales creates a level playing field, where everyone uses the same tools to describe their experiences. Over time, these scales help clinicians make informed, data-driven decisions about treatment continuation or adjustments.In the ever-evolving world of health technology, offers the potential for seamless data sharing among stakeholders in mental health care, including clinicians, patient peer communities, and digital therapeutics. This collective data can paint a more holistic clinical picture, providing clarity on what treatments work best for individual patients.Psychoeducation and Efficient Clinical Practice with MBCPicture this: routine helps clinicians ascertain a patient’s clinical status asynchronously, saving valuable time during clinical appointments. This not only shortens visit durations but also improves efficiency. With less time spent on gathering factual data, clinical discussions can focus on psychoeducation, motivation, goal setting, and shared decision-making.Using standard assessments with evidence-based scales, clinicians can align with patients on treatment targets for different therapeutic approaches. Worried about “cookie-cutter” clinical care? Periodically reconciling standardized assessments with a patient’s values and goals ensures individual treatment preferences are honored.One fascinating benefit is the reduction of hindsight and observer bias in clinical therapies. For instance, when regularly employing a score to assess responsiveness to depressive symptoms, both the patient and clinician can closely monitor symptom progression over time. Visualizing the numerical composite of core depression symptoms clarifies a patient’s historical treatment progress. This data-driven approach enables discussions about potential adjustments or modifications based on concrete evidence, rather than solely relying on subjective reports.Advancing Population Health and Resource Allocation with MBC doesn’t stop at individual care; it has a broader impact. By quantifying patient symptomatology, clinical teams can strategically allocate resources to those who need them the most. This means intensifying outreach and treatment for patients not achieving symptom recovery and quickly identifying those at risk for relapse. Symptom measurement acts as an early warning system, highlighting potential issues. also ensures that patient and clinician treatment goals are in sync, promoting timely patient discharge once recovery is achieved and sustained. This not only benefits the individual but also enhances mental health access for others in need.The Future of Mental Health Care with MBC and PsyPackIn the evolving landscape of mental health care, the time for is now. Fueled by increasing demand, reduced stigma surrounding mental health treatment, and substantial investments in mental health startups, has emerged as a potent tool to enhance care efficiency, standardization, and outcome orientation. Its ability to identify patients with clinical remission or significant responses enables clinicians to meet the growing demand for mental health services.As practitioners adapt to this shift, technology integration, patient-reported outcome measures, and third-party software solutions are streamlining the implementation of in clinical workflows. It’s a low-cost strategy that aligns seamlessly with the triple aim of U.S. healthcare, focusing on cost reduction, improved patient health outcomes, and a better overall patient experience.In this transformative journey, tools like , an innovative telemedicine solution, are leading the way. empowers behavioral health professionals to seamlessly integrate into their practice, saving time and enhancing the quality of care. With , clinicians can efficiently gather and analyze patient data using tools like the PHQ-9 and GAD-7, paving the way for personalized care and better treatment outcomes.The convergence of increased demand, innovative technology like , and a shift towards value-based care makes a critical component of modern mental health services. The future of mental health care is now, and is the compass guiding the way.
Team PsyPack
Team PsyPack
Fri Nov 10 2023

CPT Codes for Behavioral Health Practices

A CPT code, or Current Procedural Terminology code, is a standardized code set used in the United States to identify a service or procedure by qualified healthcare professionals. CPT codes were developed and are maintained by the .CPT codes are five digit numerical codes and are organized into three main categories: Reimbursement and CPT CodesPayments from insurance companies for different CPT codes drastically vary. To understand the earning potential, therapists – particularly the ones running their own private practices, must understand the state of insurance within the mental health industry.Most used CPT Codes by TherapistsCPT Code 90837 – Psychotherapy, 60 minutes with a patientCPT code 90837 is used to describe an extended psychotherapy session. Here are some key details about CPT code 90837: The insurance reimbursement amount for CPT code 90837 may be higher compared to shorter therapy sessions (e.g., 90834 for 45 minutes). It’s important for therapists to meet the necessary criteria and documentation requirements to justify billing for an extended session using CPT code 90837.CPT Code 90834 – Psychotherapy, 45 minutes with a patientCPT code 90834 is used to describe a standard psychotherapy session. Here are some important details about CPT code 90834: The insurance reimbursement amount for CPT code 90834 may be different from other therapy session codes, such as shorter sessions (e.g., 90832 for 30 minutes) or extended sessions (e.g., 90837 for 60 minutes).CPT Code 90791 – Psychiatric diagnostic evaluation, without medical servicesCPT code 90791 is used to describe an initial psychiatric diagnostic evaluation. Here are some important details about CPT code 90791: The evaluation typically involves a comprehensive of the patient including psychiatric history, current symptoms, social and developmental history, and relevant clinical information. It includes a detailed interview with the patient, potentially involving family members or collateral sources, to gather information necessary for an accurate diagnosis and .Many clinicians often overlook the use of CPT code 90791, which is . Instead, they jump straight to billing 90837 or 90834. This is a common error made by practitioners, causing them to miss out on the advantages and benefits associated with properly utilizing code 90791. The most significant advantage being the reimbursement rate for 90791 which is almost always higher than 90837 and 90834.Billing 90834 v/s 90837?Insurance companies typically consider the CPT code 90834 as the standard for outpatient routine care, unless there are unique circumstances involved. Many therapists bill this code for sessions lasting around 50 minutes. However, if the session extends beyond 53 minutes of actual clinical time (excluding scheduling and administrative tasks), the CPT code 90837 is used.Pushback from insurance companiesIf a contracted therapist frequently bills the CPT code 90837, there is a greater likelihood of undergoing a review or audit by the insurance company. This is especially true if the insurance company is providing a higher reimbursement for the 90837 code.In recent years, insurance companies have raised concerns regarding the use of CPT code 90837. Back in 2015, EquiClaim, acting on behalf of Anthem Blue Cross Blue Shield, sent letters targeting certain clinicians who frequently billed 90837. While the intention of these letters was to provide information, they carried an implication that therapists would need to provide extensive medical records if they continued to use 90837, and could potentially face audits.Although Anthem Blue Cross Blue Shield apologized for the tone of these letters, providers across the country have received similar communications from Blue Cross and other health plans. These letters inform providers that they are using 90837 more frequently compared to their colleagues and sometimes suggest contacting the Education Team for further discussion.Tips for billing 90837Here are key things to keep in mind while billing 90837; Underutilized CPT Codes by TherapistsCPT Code 90846 – Family psychotherapy (without the patient present)CPT code 90846 is used to describe a family psychotherapy session without the patient present. Here are some important details about CPT code 90846: Something to be aware of when billing 90846 is that even though the identified client isn’t present, the session still needs to be centered around the identified client’s illness or condition—not the couple or family.CPT Code 90839CPT code 90839 is used for appointments that require urgent assessments and examination of the client’s mental state. Here are some important details about CPT code 90839: Note that the definition of a crisis is really left to the therapist’s clinical judgement. However, examples of this may include clients displaying suicidal behavior or other extreme distress or psychological symptoms where the therapist may need to mobilize resources to reduce potential trauma. Two assessments available on PsyPack Assessments are particularly helpful to screen and assess for self-harm – and . Conducting psychological tests can be helpful in strengthening your documentation and justifying the use of a particular billing code.Closing notesAs a therapist accepting insurance, it’s a good idea to get empaneled with multiple insurance companies. Using the correct CPT code can make a significant difference in your earnings. You must always be prepared to defend the CPT Code you use. So documentation becomes very important. Using can help you build a defensible justification for the use of a particular CPT Code.
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Team PsyPack
Tue Jun 06 2023

Mental Health Softwares for Therapists in Private Practice

First of all, let me congratulate you If you are a therapist in private practice. From my experience of speaking with over hundred psychologists in private practice, it is incredibly difficult decision for many to take the leap of faith and leave the comfort of a “job” and follow their entrepreneurial instincts to starting their own “business”. Starting your own business means branding – naming your practice and getting that right logo with the perfect color scheme, getting out of your comfort zone and advertising your practice, getting yourself listed on various therapy listing websites, managing your practice – appointments and billing and invoices, filing taxes and maintaining books and filing for insurance claims. 😮‍💨For the brave ones, we have compiled a list of our favourite mental health softwares, EMRs and EHRs. Lets dive in;Best mental health software for a therapist websiteMarketing as a private practitioner is fun for a few therapists like the one’s who pop-up frequently on your TikTok and Instagram feeds, while it can be hard for the ones who are more introvert like me. The most critical element in marketing is getting the right website. The right website can be instrumental in getting you more inquiries from your prospective clients. A few things you must look at while selecting a software for your website are ease of building and maintaining a website, SEO, HIPAA compliant inquiry form, and last but not the least the design. I have seen many therapists spend thousands of dollars to make their websites fancy. I would say, don’t be so fixated on design and animations because really it’s the performance that matters. Here are two of our favourite website softwares,PracticeID Websites – Modern and HIPAA compliantPracticeID has just launched in 2023. And we are very excited to see a website builder solely focussed on therapists in private practice. They swear by the performance of their websites and we were happy to see that they are best in SEO by far. Another beneficial feature is the HIPAA compliant inquiry form. We love the modern approach. And they also have a free forever plan. Check them out at – .Brighter Vision Websites – The OGBrighter Vision has been around since over a decade and they really started pushing the quality of websites for therapists ever since their launch in 2011. They have tried their hands at other things like social media automation etc. but their star product has been websites. In 2020 EverCommerce acquired BrighterVision and there has been limited innovation since then. But we still love their websites and hope that they innovate more often. Check them out at – .A word of caution, we would suggest you stay away from your mental health EMR’s free website (like Simple Practice or Therapy Sites) because really they are not optimised for performance. Don’t get me wrong, but these softwares are better at practice management than at websites. Websites these days are highly sophisticated and you should use a specialised software for that.Best mental health software for practice managementOnce you have your web presence sorted and you are getting a steady stream of clients, you will face challenges with managing your practice. Think about calendar management, appointment booking, billing and invoicing etc. There are plenty of EMR and EHR available on the market but a few stand out. Most of these EMRs are quite generic and can be used for a private practice, a group practice or a behavioral health clinic.Simple Practice – The omnipresent getting expensiveI won’t believe you if you tell me that if you have never heard of Simple Practice before. They have been pioneers in EHR software for behavioral health. While they have a comprehensive solution – calendar, scheduling, appointment booking, client portal, telehealth and video calls, documentation, invoices and billing, payments, insurance and claim filing; BUT they have been constantly increasing prices. And as a private practitioner these abrupt increases might not be sustainable! Check them out at – .TherapyNotes – The Inflexible OGTherapyNotes has been there forever as well. And the good thing is that it seems less technical and it works. I have found it fast and responsive. The CC fees are also among the lowest. And yes, this one is decently priced.You will find TherapyNotes rigid though – less features, limited and non-customisable progress note, intake and treatment plan paperwork formats. Further, the schedule view is pretty old school and almost hurts looking at. They are at – .Between Simple Practice and TherapyNotes, here is the verdict from one of the Reddit threads;Best mental health software for psychological testingIt has been established that more evidence leads to better clinical outcomes. Using psychological testing routinely in your practice can help you diagnose the underlying illness better, base your treatment to the progress the client is making, and improve client’s confidence in the therapeutic process. While this space was dominated by the large corporations, like Pearson and PARInc, whose solutions are prohibitively expensive for therapists in private practice, new age startups are not only challenging these companies but also modernising the entire psychological testing journey.PsyPack Outcome Tools – Intuitive and HIPAA compliant NovoPsych – The OGNovoPsych is the OG software for psychological testing from Australia. While the library of assessment is large, the software itself is dated and lacks modern features. It is also unclear if it is HIPAA compliant or not. If you are not in the US and you have a limited usage, NovoPsych will not disappoint. Here you go – .Innovative mental health softwaresHeard – Mental Health Software for FinancesHeard is a software-enabled company that helps therapists with their finances, more specifically bookkeeping, taxes, and payroll. Heard states they can save you 60 hours per year in financial record keeping, which means you can use that extra hour or so per week finishing your notes or making money in sessions.With tonnes of VC funding, Heard is sure making some heads turn. They are at – .Upheal – AI Progress NotesTaking notes can be daunting. Well, AI is here to rescue. Upheal securely records the therapy session, automatically generates a transcript, and then use it as a basis for AI models to create progress notes and insights.Their early access program is live, go check them out at – .Delegating mechanical work to a software can really help you make time for the more important parts of your work. If you are a therapist in private practice, I will highly encourage you to adopt technology in this day-and-age of telehealth to stay ahead of the curve.If you found our list of behavioral health softwares useful, do share it with your therapist friends. 🫶
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Team PsyPack
Wed Apr 26 2023

The story of the incredible PHQ (Patient Health Questionnaire)

There’s no other assessment as popular as the PHQ-9 (Patient Health Questionnaire 9) and the GAD-7 (Generalized Anxiety Disorder 7). These are not just popular among psychologists and therapists but even the general population are familiar with these assessments. And I know, for a fact, that many doctors just know ONLY about the PHQ-9 and GAD-7 when it comes to psychological tests. Let me just provide you some interesting facts to establish the omnipresence of these two assessments; History of the PHQThe PHQ is a self-administered version of the PRIME-MD. So what is PRIME-MD? In the mid 1990s, researchers ( Robert L. Spitzer, MD, Janet B.W. Williams, DSW, and Kurt Kroenke, MD, and colleagues) at the Columbia University realised that recognizing signs of mental health disorders is not always easy. And to solve this, they went on to build the PRIME-MD, a diagnostic tool containing modules on 12 different mental health disorders. And the pharmaceutical giant Pfizer Inc. funded this project. Although the copyright of the PHQ-9 is with Pfizer, it has kept the access open to all to stay true to the original intent to enable clinicians easily recognize signs of mental illness stays intact.The PHQ, a self-administered version of the PRIME-MD, contains the mood (PHQ-9), anxiety, alcohol, eating, and somatoform modules as covered in the original PRIME-MD. The GAD-7 was subsequently developed as a brief scale for anxiety. The PHQ-9, a tool specific to depression, simply scores each of the 9 DSM-IV criteria based on the mood module from the original PRIME-MD. The GAD-7 scores 7 common anxiety symptoms.Patient Health Questionnaire (PHQ) Family of MeasuresLet us have a quick look at the most commonly used versions of the PHQ scales and their scoring;More detailed information – scoring, interpretation, printable PDF etc. about the popular assessments in the PHQ is available at; Who is the PHQ for?Age rangeMost of the PHQ scales have been validated for ages 13 years and above.TranslationsDue to it’s popularity and demand by clinicians, researchers, social workers and therapists, the PHQ has been widely translated into numerous languages; Please note the above list of languages is not exhaustive.Criticism of the PHQWhile the PHQ assessments are insanely popular. But this does not come without any criticism. In the defence of the questionnaire, all such tools serve the purpose of screening and must be followed up with a clinical interview with a professional to establish diagnosis.PHQ with PsyPack AssessmentsIf you are a therapist, social worker, GP, you can easily conduct the PHQ-9, GAD-7 and PHQ-15 online with PsyPack online assessments. PsyPack can help you conduct psychological assessments via tele-health easily. PsyPack is an online software to help psychologists, therapists, social workers and counselors, administer psychological tests online to their clients, score tests automatically, and prepare detailed reports in a fraction of second. It helps you store your clinical records of your testing in a HIPAA compliant manner.PsyPack comes pre-loaded with numerous standardised psychological tests. Staying true to the spirit of the PHQ, we have included PHQ-9 and the GAD-7 in the free forever Beginner Plan of PsyPack. Try PsyPack now; References
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Team PsyPack
Wed Jan 04 2023

SOAP Notes – Example, Template and Format

What is a SOAP note?The Subjective, Objective, Assessment and Plan (SOAP) note is an acronym represents a cognitive framework to help healthcare professionals organise treatment information of a client in a highly structured format.SOAP Notes template with exampleA SOAP note is structured into four parts;SubjectiveThis section focusses on the subjective experience of the patient or their caretaker. It includes the symptoms they are experiencing, feelings w.r.t. the illness, medical history, previous diagnosis (if any), and their personal views. Simply put, this is what the patient says about their problem.Example: 37-year old female presenting chest pain, decreased appetite and shortness of breath. Diagnosed with mild depression 1 year ago. Underwent psychotherapy for 3 months. Recent physical manifestations concurrent with family feuds.ObjectiveThe focus of this section is on objective data. This includes vital signs and symptoms, findings of the clinician, laboratory diagnostic data and objective reports from other clinicians. Unlike the “Subjective” section which gives a description of patient’s own account, the “Objective” section is backed by evidence. An example of this is a patient stating they have “stomach pain,” which is documented under the subjective heading. Versus “abdominal tenderness to palpation,” an objective sign documented under the objective heading.Psychological tests like , , etc. are particularly useful at this stage since they are objective in nature.Example: The client's results on the signals moderate depression, extremely severe anxiety and mild stress.It is recommended that you store the data in the client’s file securely in accordance with HIPAA . is a HIPAA compliant software you can use to conduct with your clients. It can help you maintain client notes automatically and save you tons of time.AssessmentThis section is the clinician’s analysis of the subjective and objective evidence to arrive at a diagnosis.For behavioral health practitioners, one would generally expect a differential diagnosis where they would list various problems in order of importance. At this stage, therapists could mention ICD-10 or DSM5 classification of the illness. This can be particularly helpful for therapists who are empanelled and accept insurance plans like United Healthcare, Aetna, BlueCross and BlueShield etc.Example: Client is most like suffering from Generalized Anxiety Disorder (ICD-10 code F41.1)PlanThis section details the treatment approach – interventions, goals/objectives of the intervention, expected time frame, and follow-up and next steps.Therapists could weigh various psychotherapy approaches like CBT, EMDR etc. at this stage to plan. Additionally referrals to psychiatrists can be considered to pharmacotherapy.In case, further information is required for planning the treatment, this section will include plan (additional testing, consultation with other clinician etc.) to obtain the required information.Example: Immediate initiation of pharmacotherapy and, if severe impairment or poor response to therapy, expedited referral to a mental health specialist for psychotherapy and/or collaborative management.DAP Notes and BIRP NotesSOAP notes are not the only format available for charting treatment. The other popular approaches include DAP (Data, Assessment, and Plan) and BIRP (Behavior, Intervention, Response, Plan). Among all these formats, SOAP notes format is most widely used.You should choose the format of documentation based on what’s best suited to your practice. But having a framework can be really helpful.  “One of the biggest problems I see with new therapists,” says  “is a lot of anxiety about how to write adequate professional notes. So many new therapists haven’t been adequately trained and carry a lot of anxiety about having their records audited. Following an official framework, like SOAP notes, can really help relieve that anxiety.” Additionally, you must be wary to not adjust your treatment to fit any particular format. Always remember, treatment notes follow the treatment and not vice versa.PsyPack Practitioner’s NotesAt , we are constantly working to ensure that therapists are empowered with technology to streamline their practice. Apart from helping you embrace evidence based approach by digitising a , we now allow you to add your own therapy notes to the assessment reports. You can now add notes in any format in the “Practitioner’s notes” section of reports. .Today the world is increasingly moving towards mandatorily maintaining treatment documentation. A part of this shift is to ensure best practices, choice of patient to switch their clinician, insurance empanelment and claim settlement etc. To stay competitive, it is critical to embrace best practices and technology in your therapy practice.
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Team PsyPack
Mon Apr 11 2022

Psychological assessments

Diversity is beautiful. But why does nature create each one of us so unique? We look different, we feel differently, we think differently, we behave differently and so on. In fact, no two of us have the same fingerprints!Why wouldn’t nature create all of us the same – something of “a standardised homo-sapien”?The challenge with such a high level of predictability is vulnerability. One adverse predator, one adverse virus, one adverse event could destroy the entire species. Diversity is not just beautiful but it is the essence of survival. Individual differences make us stronger as a species.One could imagine that since individual differences are so intrinsically linked to survival and nature, it makes studying them of immense value.Individuals vary in terms of physical characteristics, such as height, weight, strength, hair colour, and so on. They also vary along psychological dimensions. They may be intelligent or dull, dominant or submissive, creative or not so creative, outgoing or withdrawn, etc. The list of variations can be endless. Different traits can exist in varying degrees in an individual. In this sense, each one of us is unique as s/he exemplifies a typical combination of various traits.Behavioral health professionals and social scientists have devised multiple instruments over the years to study these differences scientifically. Psychological assessments help us study the amazing diversity in human beings and give us sneak peek into the mysterious ways of nature.What is a psychological assessment?All sciences are built on systems of constructs and their interrelations. The natural sciences use constructs such as temperature, gravity, and global warming. Likewise, the behavioral sciences use a variety of constructs or attributes. These can be very simple phenomena like time taken to react to a stimulus, i.e. reaction time, and also in highly global concepts like happiness. Behavioral health professionals study both non-psychiatric attributes, like intelligence, aptitude, interest, personality and values etc., and psychiatric constructs like depression, anxiety, somatoform disorders, Post-Traumatic Stress Disorder (PTSD) and Attention-Deficit/Hyperactivity Disorder (ADHD) etc. , a strong proponent of deliberate practice, recommends using outcome measures to improve clinical outcomes.Psychological attributes are not linear or unidimensional. They are complex and expressed in terms of dimensions. They are usually multi-dimensional. For example, if a child is having trouble in school, they might not fit strictly into a categorical diagnosis of a reading problem such as dyslexia, or an attention problem such as attention-deficit hyperactivity disorder (ADHD), or difficulty with impulse control? They might have different se­verity levels of the constituent symptoms of each of those. If you want to have a complete assessment of a person, you will need to assess how s/he functions in various domains or areas, such as cognitive, emotional, social, etc. With regards to diagnosis of mental disorders, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) favours the dimensional approach over the categorical approach.Assessment is the first step in understanding a psychological attribute. Assessment refers to the measurement of psychological attributes of individuals and their evaluation, often using multiple methods in terms of certain standards of comparison. Once assessment is done, we can use this information to predict future behavior of an individual. If the predicted consequence is not what we want, we may want to intervene to effect a change.The American Psychological Association defines psychological assessment as “the gathering and integration of data to evaluate a person’s behavior, abilities, and other characteristics, particularly for the purposes of making a diagnosis or treatment recommendation. Psychologists assess diverse psychiatric problems (e.g., anxiety, substance abuse) and non-psychiatric concerns (e.g., intelligence, career interests) in a range of clinical, educational, organizational, forensic, and other settings. Assessment data may be gathered through interviews, observation, standardized tests, self-report measures, physiological or psychophysiological measurement devices, or other specialized procedures and apparatuses.”Assessment MethodsPsychologists use several techniques for assessment;Characteristics of a good testAll measuring instruments, be it a measuring tape, a bathroom scale, medical tests like  X-rays or blood tests, or a psychological test must follow certain basic scientific principles to be any useful.ValidityA psychological test is useful only to the extent to which it actually measures what it purports to measure. For example, a test measuring a stable personality trait should not be measuring transitory emotions generated by situational conditions.There are multiple statistical methods of establishing validity;ReliabilityThe extent to which any measuring device (including a psychological test) yields the same result each time it is applied to the same quantity. For example, the measuring tape should not measure your height differently when measured by two different people. It must be consistent. Several different methods exist for assessing a psychological test’s reliability;NormsYou would never compare scores of two students from, say grade 5 and grade 10, on a mathematics test. Clearly, that would be unfair. Similarly, psychological constructs are also relative in nature. For example, constructs like intelligence are not absolute, but measure standing of an individual relative to a group. Test norms consist of data that make it possible to determine the relative standing of an individual who has taken a test. By itself, a subject’s raw score (e.g., the number of answers that agree with the scoring key) has little meaning. Almost always, a test score must be interpreted as indicating the subject’s position relative to others in some group. Norms provide a basis for comparing the individual with a group.To ensure fairness, it is essential that the norms used to assess an individual are based on a population which is representative of that particular individual.Ethics of assessmentsPsychological tests serve many useful purposes such as selection, counselling, guidance, self-analysis, and diagnosis. Unless used by a trained practitioner, they may be misused either intentionally or unintentionally. A practitioner is expected to follow certain ethics (or moral principles) while conducting the tests.The future of psychological testingWhile telemedicine and digital tools have become increasingly common over the past few years, the COVID-19 pandemic has super-charged and accelerated the adoption of telepsychology. Practice management tools like help psychologists, therapists, social workers and counselors to conduct not just likert scale assessments like , , etc. but also digital tasks based assessments like and .Startups like and are beginning to provide game-based psychometric evaluations to assess attention, decision making, risk tolerance etc., for the hiring process. ‘Gamified’ assessments are more engaging than traditional psychometric tests.Further the use of artificial intelligence (AI), including facial recognition and text analysis software, in psychometric assessments are promising in supplementing a clinicians’ efforts to spot mental illnesses earlier and improve treatments for patients. Computers could be trained to analyse a variety of data – mobility, physical activity, facial expressions, sleep patterns, typing behavior, body language and more. Apple is already working on iPhone features to help detect depression and cognitive decline. Although promising, these technologies first need to be shown to be effective. Additionally, some experts are wary of bias and other ethical issues as well.
Team PsyPack
Team PsyPack
Mon Oct 04 2021