I'm Dr. Maelisa McCaffrey and I started QA Prep to teach therapists how to create rock solid documentation so they can spend more time focusing on clients and less time worrying about paperwork!
Each Wednesday you'll find a new video answering therapist's questions about mental health documentation. We talk progress notes, treatment plans, therapy forms for private practice, and dealing with insurance.
I also post videos on any and everything related to technology for clinical documentation, HIPAA, time management and more.
Connect with our community via frequent livestream Q&A sessions, or post your own tips in the comments section of regular videos.
Thanks for your series reviewing AI clinical note tools - we are currently looking at both an EHR and notes tools so this has been invaluable, especially your testing with Rodgers' Gloria session. Looking forward to your review of Heidi and the EHR reviews.
I am a clinician at group practice for first time. I assumed I would have supervision/or group consultation with other clinicians. But they don’t make time for that. It is kinda disappointing because I was solo prior and finally decided to be with others for support. I still feel so alone at a place with 3 other full time therapists. All these of these things is how I feel. ❤
hehehe...I need 3 for this project I'm working on, but this certainly gets me moving in the direction I to be going in, Thank you so much for your good insights.
This is great! I believe you said you would share a checklist and a link for your Privacy Policy but I do not see either, I may have misunderstood. Thank you! :)
Hi I have a question For subjective and objective complaints body part mentioned are spine and right shoulder However for intervention performed for hot moist pack and EMS spine is mentioned and for therapeutic exercise and neuro muscular education just time is provided so will we consider that for right shoulder based on subjective and objective complaints???
Thank you for this overview!! Very helpful! I just did a demo with them and they have added the customization feature allowing the clinician to limit the length of the casenotes and they are going to add the ability to integrate with Simple Practice "soon."
Hi Maelisa, in the sample notes that I downloaded of "Gloria" from your session, you have something about "as is" notes and notes "with additional prompts." What do you mean by that? Can you converse with the AI to get it to improve the note?
Some of them allow you to provide additional prompts to improve the note. And some allow you to further personalize the template by providing additional prompts within the template provided.
Thank you so much, this was very helpful! I've been in the midst of creating my forms for some weeks and this video confirms I'm on the right track, which makes me feel really good because I've stressed out over a lot of this (not just the forms, but getting the whole practice together). I need to check and possibly tweak a few things, but I believe I'm finally close to being done with all my paperwork. Thanks again Maelisa, several of your videos have been helpful to me in this process. 🙂
Thank you for your videos! My wife is a new therapist and is looking for a therapy notes software or website that helps her with reducing the amount of time she takes to do notes. I’ve watched a few videos you’ve produced and really appreciate them! I have a few questions I’d love to run by you for your advice: 1. Could you share which “notes only” software/website product you like the best that also includes AI? 2. I’ve looked at Note Designer as another option to consider and wanted to also get your feedback on that product? 3. Do you have any video reviews on it?
I don't have any reviews on Note Designer. I hear mixed opinions - for some it is overwhelming while others find it helpful. I recommend going through it (or any other resource like it) and identifying the top 10-15 helpful phrases. Copy those down to use and then don't worry about looking at it again.
As far as a favorite AI progress note generator, I really don't have a favorite. They are all different and it's based on personal preference and budget.
I appreciate your videos so much as note writing has been such a challenge for me. I’m an Associate and my agency will not allow us to use bulletpoints citing that insurance companies reject any notes written in any shortcut form. You’re spot on about how laborious and excruciating it feels to me so I avoid the task. After seeing 6-7 clients a day I don’t have the mental capacity to write anything.
They’re wrong about the bullet points but when you work in an agency you have to go with their rules. Try creating starter sentences for yourself to use as a cheat sheet instead 😉
0:00 Intro 1:39 How Does it actually work? 4:39 Pricing 5:28 How well does it integrate with my EHR? 6:39 What are my favorite features? 9:05 Any cautions or concerns? 12:53 How well did it actually write a progress note? 17:00 Overall assessment 17:46 Outro
Avoid at all cost!!! They offer a trial period and then they will literally remove the cancel membership option when it is time to cancel it before you are charged!!! They only responded to me via email when they tried to charge my cc a total of 12 times and realized they weren’t going to get a dime from me!!! Then they apologized for the “backlog” that prevented me from canceling😏…I use Freed for my progress notes…yes it is more costly but much less of a headache
0:00 Intro 0:40 Concern #1 - Data 2:18 Concern #2 - AI Recordings 3:04 Three Consent Issues: Telehealth, AI and Recording consent 4:26 Do no harm 4:34 Inform your clients about the process 4:48 AI and Ethics - Be Cautious 5:14 Always Get Client Consent About Using AI 5:58 Recording 6:30 Client Access 6:41 Delete Data ASAP 7:27 Special Protection - Psychotherapy Notes 8:23 Do not be the therapist involved in the court case 8:30 Delete 8:40 Let Clients Know 8:50 Don't Be Scared Away 9:21 Test It Out - Get Training 9:35 Get Involved 9:51 Outro
Love this content! So helpful. Could you also add a CBT test session to this series? The Gloria tapes are great, but with insurance and contract companies all requiring evidence based documentation, I think this would be valuable to see how these platforms perform in that area as well. I use many different modalities but I feel CBT would be a simple straight forward example for this type of review. Thank you for all you do 🤗
I've been using Upheal for about 6 months and love it. I wish they had a group pricing option as I really enjoy using with supervision. The other templates have better interventions sections, including bullet points. I like using the Upheal or BIRP template the best.
I am a graduate student but I am also a QMHP and case manager who does crisis response a session utilizing seeking safety and motivational interviewing. Can I use this?
This video was very helpful. Al can be helpful in many ways but it can also spread misinformation. We should not consider Al when focusing on important issues. Having our own research and evaluation is still more reliable.
AI should not be used. It's not human intelligence and writing is important for intellectual processes that could lead to further conclusions about the client's problems and potential solutions that would otherwise be missed. Notes are "for" the client and a part of treatment, not just an ethical and legal requirement but a tool for clinical judgment.
I have to respectfully disagree. The idea that every therapist uses notes in this way is simply not true. Not every person processes through writing. In fact, writing can take people out of that process sometimes. I say this as 1) a psychologist who used to specialize in learning disorder testing and then in ADHD and 2) as someone who is actually more like you and does process through writing and had to learn that does NOT work for everyone. In addition, many therapists with whom I work are so focused on what “should” be in a note that they don’t have the time or capacity to use notes for case conceptualization. Yes, it would be ideal to do that, but in my experience that’s more rare. Even therapists who do that well get stuck in the “problem of the week” since overall conceptualization requires looking at the full record regularly, too. While I don’t think AI should be used by everyone, we have lots of resources guiding people in how to use it ethically. Thats the key. More than one therapist has used the phrase “life changing” to describe how using AI for progress notes helped them. We cannot ignore that AI meets a very real need, and that it is possible to use it ethically… and that in some circumstances, AI can even make you a better therapist.
Thanks Maelisa for doing all the research on the different AI. I guess I'm just not ready with all the extra work to get a progress note completed with AI. I utilize your paperwork and have cut down on a lot of my lengthy wording!!! Thank you:)
That’s awesome! I think a good template can do the same thing, but understand that AI is helping a lot of people with the mental effort part of things.
Thank you, excited to try this one! Dictation + custom templates is what I’m looking for (without it being an EHR). Too bad it makes up quotes. Hopefully they fix that. Note: it seems they don’t do free trials anymore. And there is one price: $95 per month.
Thank you, and let us know what you think if you try it! They do have a discount code for 50% off: Use code “qa24” To reiterate, that’s not an affiliate code and I receive no compensation.
The user experience is very different since Orchid is set up as an EHR. If you like your current EHR, maybe try SessionAid as a companion. Otherwise, Orchid would give you a complete solution. In terms of comparing the two: I like the finished look of the note better on SessionAid, but it was a little easier to set up the custom template (and adjust it later) in Orchid. And I think both companies are improving both of these aspects, so it’s really just a matter of preference.
Perfect...I do this and it works beautifully!! So glad you are talking about all this Maelisa even if it was a year ago, new folks can you this solid, well informed information. I find that in providing time for the clients to do it ahead of time, I can a more thorough bio/psycho assessment:)
Thank you, Maelisa! I just added my name to the waitlist for the paperwork catch up group. It feels good to have community and know it is not just me alone.
Maelisa I listen to you alot...and of course as a licensed therapist I need 36 BBS hours. Have you ever thought about making these You Tubes with a test at the end and providing 1 hour BBS qualifying training? I also work with your paperwork in particular your examples of treatement plans and progress notes: I like the one that has topic/intervention/client participation and plan,, which obviously isn't soap, dirt or dap, but as I work in private practice alone, cash, no insurance it works out well...I am working on getting them from hard copies into click boxes, but its a struggle for my lack of knowledge. Have you ever thought of making your paperwork electronic?
As of right now, it’s just electronic document templates that people can use if their EHR allows them to create their own template. You could also use them within Google Workspace. But it would be far too much effort to create an electronic system for my templates without it being an EHR itself… it would end up being an additional tool (with added cost) and an additional step. Now if the EHR wanted to make my templates available within their system, that would be ideal! Will see if we can make that feasible in 2025 😉
