Therapy sessions documented without a laptop between you and the client.
DAP and BIRP progress notes from a full session, with scores recorded and homework carried into the plan. Psychotherapy notes stay separate.
Behavioral health
DAP progress note
median time to a signed progress note, down from 16
of notes finished before the next session starts
Measured over a 12-week pilot at the clinic quoted on this page.
A sample visit and the note drafted from it.
Visit transcript
[02:10] Therapist: Last time we set up the breathing exercise for nights you can't sleep. How did that go?
[02:16] Client: Better than I expected. I used it four nights and fell asleep faster on three of them.
[14:32] Therapist: What took up most of your worry this week?
[14:37] Client: The quarterly presentation. I keep replaying how it could go wrong.
[41:05] Therapist: Your GAD-7 today is 10, down from 14 last month. This week, let's try a set worry time each evening.
[41:20] Client: Fifteen minutes after dinner. I can do that.
Draft note
Data: Client used the breathing exercise on 4 nights and fell asleep faster on 3. Main worry this week is an upcoming work presentation, with repeated rumination about it going wrong. Anxiety score (GAD-7) 10, down from 14 last month.
Assessment: Generalized anxiety disorder (per treatment plan), improving. Client is applying skills between sessions.
Plan: Scheduled worry time, 15 minutes after dinner each evening.
Suggested code: F41.1 Generalized anxiety disorder
Fictional patient. Transcript shortened for this page.
How the clinic uses Charted.
Brisell Behavioral Health has 18 therapists and 2 psychiatric nurse practitioners. With sessions booked back to back, notes either took the 10 minutes between clients or waited until evening. Typing during sessions wasn't an option for most of the team.
Each session starts with the consent prompt on the therapist's tablet. Charted drafts a DAP or BIRP note in the clinic's template, records scores in the note, carries homework into the plan and leaves out small talk. Therapists can keep their own analysis of a session as a separate psychotherapy note, which stays in Charted and never goes to the shared chart. Scores, diagnosis, the plan and session times stay in the progress note.
During the pilot, median time to a signed progress note fell from 16 minutes to 5, and 92% of notes were finished before the next session started. Two therapists chose not to record couples sessions, and the clinic made that an option for the whole team.
