Psychiatry practice management and EHR and EHR software that handles therapeutic sessions and medication complexity

Psychiatric practices balance psychotherapy requiring detailed session documentation, medication management demanding safety monitoring, and diagnostic assessment needing structured evaluation. Generic EHR systems lack mental status examination templates and medication tracking tools. Basic billing software misses psychotherapy add on codes and measurement based care billing. Harris CareTracker delivers practice management software built specifically for psychiatry workflows where documentation supports therapeutic care and billing accuracy protects revenue from complex coding rules.

Why Choose Us?

Comprehensive diagnostic assessment documentation

Initial psychiatric evaluation requires extensive history gathering across multiple domains. Presenting symptoms, psychiatric history, substance use, trauma exposure, medical conditions, medications, family history, social circumstances, and comprehensive mental status examination.

Harris CareTracker evaluation templates guide systematic assessment ensuring completeness supporting diagnosis and treatment planning.

Initial psychiatric evaluation template

Comprehensive evaluation documents chief complaint in patient words, detailed history of present illness with symptom onset and progression, past psychiatric diagnoses and treatments, psychiatric hospitalizations, suicide attempts, substance use history, trauma exposure, medical conditions affecting mental health, current medications, family psychiatric history, developmental history, social history including relationships and occupation, and complete mental status examination.

Structured evaluation ensures diagnostic thoroughness while supporting appropriate billing for comprehensive psychiatric diagnostic evaluation.

Mental status examination documentation

Mental status examination assesses appearance, behavior, speech, mood, affect, thought process, thought content, perceptions, cognition, insight, and judgment. Findings support diagnostic formulation and safety assessment.

Templates organize mental status by domain with dropdowns for common findings and text fields for detailed abnormality description.

Systematic mental status documentation supports diagnosis while fulfilling evaluation complexity requirements for billing.

Session Notes Templates Supporting Therapeutic Care and Billing

Psychotherapy sessions require documentation supporting medical necessity, therapeutic interventions delivered, patient progress, and treatment plan adjustments. Documentation must satisfy both clinical and billing requirements.

Psychotherapy session note structure

Session notes document presenting concerns, interventions provided, patient response, progress toward treatment goals, homework or between session tasks, safety assessment, and plan for next session.

Templates balance clinical utility with billing compliance. Intervention types specified supporting specific psychotherapy codes. Time tracking for time based billing. Medical necessity elements ensuring coverage.

Session notes support both therapeutic continuity and appropriate psychotherapy code selection.

Psychotherapy with medication management combination billing

Many psychiatric visits combine psychotherapy with medication evaluation. Billing requires both psychotherapy code and E and M code with modifier 25 when documentation supports medical necessity for both services.

Automated billing logic identifies sessions including both components. Verifies documentation supports separate billable services. Applies modifier 25 preventing denials.

Psychiatric Medication Tracking with Safety Monitoring

Psychiatric medication management involves multiple medications, frequent dosing adjustments, side effect monitoring, drug interactions, and laboratory surveillance. Longitudinal tracking essential for safe prescribing.

Medication Regimen Tracking and Adjustment History

Psychiatric patients often take multiple psychotropic medications. Medication list shows current regimen but lacks historical context. Prior trials, doses attempted, discontinuation reasons, and response patterns inform future decisions.

Medication timeline displays current and past medications. Start dates, stop dates, maximum dose reached, discontinuation reason, and effectiveness rating. Visual timeline shows medication changes in context with symptom patterns.

Comprehensive medication tracking prevents repeating failed trials and supports informed prescribing decisions.

Laboratory Monitoring for Psychiatric Medications

Multiple psychiatric medications require laboratory monitoring. Lithium levels, valproate levels, clozapine monitoring with absolute neutrophil count, antipsychotic metabolic monitoring including glucose and lipids, and baseline labs before medication initiation.

Monitoring protocols define required labs by medication. Alerts generate when labs overdue. Results trend over time connecting lab values with medication doses.

Systematic lab monitoring improves medication safety while ensuring compliance with monitoring requirements.

Side Effect Monitoring and Documentation

Psychiatric medications cause significant side effects affecting adherence. Weight gain, metabolic changes, sexual dysfunction, sedation, akathisia, and extrapyramidal symptoms require monitoring and management.

Side effect screening tools assess common problems systematically. Severity rating guides intervention decisions. Documentation supports medication changes when side effects outweigh benefits.

Side effect monitoring supports informed prescribing and demonstrates medical necessity for medication changes.

Symptom Tracking and Outcome Measurement

Measurement based care improves psychiatric outcomes. Standardized instruments quantify symptom severity, track treatment response, and guide clinical decisions. Billing supports measurement administration and interpretation.

Standardized assessment instrument integration

Depression screening with PHQ 9, anxiety assessment with GAD 7, bipolar symptoms with MDQ, PTSD screening with PCL 5, and ADHD rating scales provide objective symptom measurement.

Instruments integrate with automatic scoring. Results trend over time showing treatment response. Billing codes generate for administration and interpretation.

Measurement based care integration supports evidence based practice while generating additional revenue from assessment billing.

Outcome tracking and treatment response monitoring

Treatment effectiveness assessment requires comparing baseline symptoms to current status. Response defined as 50 percent symptom reduction. Remission as minimal residual symptoms. Treatment failure as inadequate improvement after adequate trial.

Outcome tracking displays symptom trajectories. Identifies non responders requiring treatment modification. Documents treatment adequacy for insurance authorization of advanced interventions.

Systematic outcome tracking improves treatment decisions and supports authorization for intensive treatments when initial approaches fail.

Suicide Risk Evaluation and Safety Planning

Psychiatric practices require systematic suicide risk assessment and safety planning. Risk factors, protective factors, current ideation, intent, plan, access to means, and historical attempts inform risk stratification and safety interventions.

Suicide Risk Assessment Documentation

Risk assessment documents suicidal ideation presence and characteristics, intent to act on thoughts, specific plans, access to lethal means, substance use increasing impulsivity, recent stressors, past attempts, family history of suicide, protective factors including reasons for living, and risk level determination.

Systematic risk assessment supports safety interventions and documents medical decision making.

Addiction Treatment and Medication Assisted Treatment

Psychiatry practices treating substance use disorders need medication assisted treatment documentation, urine drug screening tracking, and treatment response monitoring.

Buprenorphine for opioid use disorder, naltrexone for alcohol use disorder, and medication management for co-occurring mental health conditions require systematic tracking.

Substance Use Treatment Features

MAT Documentation and Monitoring

Buprenorphine induction documentation, maintenance dosing, treatment adherence, urine drug screening results interpretation, and diversion risk assessment.

SBIRT Documentation

Screening for substance use, brief intervention with motivational techniques, and referral to treatment when indicated. Billing codes for screening and brief intervention.

Recovery Monitoring

Abstinence tracking, relapse documentation, triggers identification, coping skills assessment, mutual help group participation, and treatment plan adjustment based on progress.

Document Psychiatric Sessions During Therapeutic Conversation

Psychotherapy sessions require full attention to patient communication. Typing during sessions interrupts rapport, distracts from nonverbal cues, and reduces therapeutic presence. Traditional documentation after sessions creates backlog extending work days.

Amplify by Harris CareTracker captures psychiatric encounters through ambient listening. Record the session. Therapeutic conversation flows naturally. AI transcription organizes into session note structure. Review and finalize minutes later focusing on clinical additions beyond conversation content.

Psychotherapy session documentation during treatment

Therapy sessions involve patient reporting symptoms and concerns, therapist interventions using specific techniques, patient responses to interventions, skills practice, and homework assignment. Capturing therapeutic dialogue enables comprehensive session notes.

Ambient listening records session conversation. Patient describes mood symptoms. Therapist uses cognitive restructuring techniques. Automatic thoughts identified and challenged. Behavioral activation planned. Homework assigned. AI structures into session note format.

Complete session notes from therapeutic conversation. Documentation time reduces from fifteen minutes to three minutes reviewing and finalizing.

Medication management appointment efficiency

Medication visits involve reviewing current regimen, assessing effectiveness, screening for side effects, evaluating adherence, discussing lab results, and adjusting treatment. Capturing conversation enables efficient documentation.

Speak about medication response. Ask about side effects. Discuss lab results. Explain dosing changes. AI documents entire medication evaluation organized by medication management elements.

Medication management documentation in minutes. Conversation flows naturally without typing interruption.

Psychiatric evaluation comprehensive capture

Initial psychiatric evaluations involve extensive history gathering. Chief complaint, symptom timeline, psychiatric history, substance use, trauma, family history, social circumstances. Typing during evaluation interrupts patient narrative flow.

Ambient listening captures comprehensive history through conversational interview. Patient tells story. You ask clarifying questions. Chronology emerges naturally. AI organizes into structured evaluation format.

Ninety minute evaluation documented comprehensively. Post session review takes ten minutes versus forty minutes traditional typing.

Psychiatry Practice Management and EHR Built for Therapeutic Documentation and Complex Billing

What Our Customers Say About Us

We chose Harris CareTracker for our office because of its cost-effectiveness and since changing to them, we have seen a significant increase in our monthly savings. The standout feature has been the excellent customer support and training!

Tara Warnock

Billing Specialist | Naples Vascular Specialists

It’s really easy to use Harris CareTracker Practice Management. Very easy to learn.

Lauren O'Brien

Billing Manager | New England OB/GYN

We have used Harris CareTracker in our practice for 5 years, and it has been a wonderful experience. The trainers and on-going support teams are knowledgeable, accessible, and quick to respond to queries. They provided easy-to-follow step-by-step guidance for using the software. They never failed me. I highly recommend CareTracker for practices of any size.

Psychiatry practice management and EHR and EHR software that handles therapeutic sessions and medication complexity

Why Choose Us?

HIPAA-Compliant Psychiatric Evaluation & MSE Templates

Medication Tracking & Safety Monitoring

Automated Psychotherapy & E/M Billing

Comprehensive diagnostic assessment documentation

Session Notes Templates Supporting Therapeutic Care and Billing