AI Scribe for Psychologists
Document therapy sessions, assessments, and treatment plans in seconds. PatientNotes captures clinical observations, interventions, and generates HIPAA-compliant mental health notes.
Documentation for Every Psychology Visit
From therapy sessions to psychological assessments, PatientNotes handles all mental health documentation needs
Therapy Sessions
Individual, couples, family, and group therapy session notes with presenting issues, interventions, and clinical observations.
Psychological Assessments
Comprehensive evaluations including clinical interviews, mental status exams, testing results, and diagnostic formulations.
Initial Evaluations
Intake assessments with presenting problems, psychiatric history, psychosocial history, and treatment recommendations.
Crisis Interventions
Documentation of crisis situations including suicide risk assessment, safety planning, and emergency interventions.
Treatment Planning
Collaborative treatment plans with measurable goals, evidence-based interventions, and progress monitoring.
Progress Reviews
Regular progress evaluations tracking symptom changes, goal achievement, and treatment plan adjustments.
Psychology-Specific Features
Built for the unique documentation needs of mental health professionals
Mental Status Exam
Structured documentation of appearance, behavior, speech, mood, affect, thought process, thought content, cognition, insight, and judgment.
Suicide Risk Assessment
Comprehensive safety evaluation including ideation, intent, plan, means, protective factors, and risk level determination.
Treatment Modality Support
Document CBT thought records, DBT skills training, exposure hierarchies, and other therapy-specific interventions.
DSM-5 Criteria Tracking
Map symptoms to DSM-5 diagnostic criteria with severity ratings and specifiers for accurate diagnosis.
Goal Progress Monitoring
Track measurable treatment goals with baseline, interventions used, and progress toward objectives.
Therapy Homework
Document assigned between-session tasks, completion status, and review of homework in subsequent sessions.
Sample AI-Generated Psychology Note
See how PatientNotes documents a therapy session
PSYCHOTHERAPY SESSION NOTE Date: [Session Date] Session Type: Individual Therapy (50 minutes) Modality: Cognitive Behavioral Therapy PRESENTING CONCERNS: Client presented for regular therapy session. Reports continued anxiety symptoms related to work stress and interpersonal conflicts. States anxiety is "about a 6 out of 10 this week" compared to 8/10 at last session. Client completed thought record homework assignment. CURRENT SYMPTOMS: - Anxiety: Moderate (6/10) - Sleep: Improved, averaging 6 hours per night - Concentration: Mildly impaired at work - Physical symptoms: Tension headaches 2-3x per week - Safety: Denies suicidal ideation, homicidal ideation, or self-harm urges MENTAL STATUS EXAM: - Appearance: Casually dressed, good hygiene - Behavior: Cooperative, appropriate eye contact - Speech: Normal rate and volume - Mood: "Stressed but managing better" - Affect: Anxious but brighter than previous sessions - Thought Process: Linear and goal-directed - Thought Content: Ruminative worries about work performance, no SI/HI - Perception: No hallucinations or delusions - Cognition: Alert and oriented x3, intact memory - Insight: Good - recognizes cognitive distortions - Judgment: Good SESSION CONTENT: 1. Reviewed thought record homework - client identified 5 instances of catastrophizing and all-or-nothing thinking related to work presentations 2. Practiced cognitive restructuring for automatic thoughts about performance evaluation 3. Identified evidence for and against feared outcomes 4. Developed alternative balanced thoughts 5. Discussed behavioral activation - client agreed to resume yoga class (discontinued 2 months ago) 6. Introduced progressive muscle relaxation technique, practiced in session INTERVENTIONS USED: - Cognitive restructuring - Socratic questioning - Behavioral activation - Relaxation training - Psychoeducation about anxiety cycle PROGRESS TOWARD GOALS: Goal 1 (Reduce anxiety symptoms): Progressing - client reports decreased anxiety intensity and improved coping Goal 2 (Challenge negative automatic thoughts): Progressing - successfully completed thought records and identified distortions Goal 3 (Improve sleep): Achieved - now consistently sleeping 6+ hours per night HOMEWORK ASSIGNED: 1. Continue daily thought records 2. Practice progressive muscle relaxation 10 minutes daily 3. Attend one yoga class this week 4. Challenge one catastrophic thought per day using evidence worksheet CLINICAL IMPRESSIONS: Client continues to make steady progress in therapy. Demonstrates good insight and motivation. Successfully applying CBT techniques between sessions. Anxiety symptoms gradually decreasing with continued treatment. PLAN: - Continue weekly individual CBT sessions - Maintain current interventions - Introduce exposure hierarchy for work-related anxiety in next session - Monitor mood and anxiety levels - Next appointment scheduled for [date]
Intelligent ICD-10 Suggestions
PatientNotes suggests the codes most commonly used in psychology
F41.1Generalized anxiety disorderF33.1Major depressive disorder, recurrent, moderateF43.10Post-traumatic stress disorder, unspecifiedF60.3Borderline personality disorderF42.2Mixed obsessional thoughts and actsF90.2Attention-deficit hyperactivity disorder, combined typeF31.9Bipolar disorder, unspecifiedZ63.0Problems in relationship with spouse or partnerAI suggests relevant codes based on your documentation—review and select with one click.
Frequently Asked Questions
Can PatientNotes document psychotherapy sessions while maintaining HIPAA compliance?
Yes. PatientNotes is fully HIPAA-compliant and maintains the highest security standards for mental health documentation. All therapy notes are encrypted and stored securely, meeting federal privacy requirements.
Does PatientNotes support different therapy modalities?
Yes. PatientNotes can document various therapeutic approaches including CBT, DBT, psychodynamic therapy, trauma-focused therapy, and more. The AI adapts to your specific therapeutic framework and terminology.
How does PatientNotes handle psychological assessment documentation?
PatientNotes documents comprehensive psychological assessments including clinical interviews, mental status exams, diagnostic impressions, and test results. It organizes findings in standard psychological report format.
Can PatientNotes track treatment progress and outcomes?
Yes. PatientNotes helps monitor symptom progression, treatment goals, and therapeutic interventions over time. It tracks changes in functioning, mood ratings, and progress toward treatment objectives.
See More Patients, Document Less
Join psychologists saving 2+ hours daily on documentation. PatientNotes handles the charting so you can focus on your patients.
No credit card required. $50/month after trial.