Diagnosis and Treatment Plans


Videos

Please see our videos on diagnosis and treatment plans.

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Adding a client's diagnosis

You can manage your client's diagnoses Diagnosis & Treatment tab. Start by clicking Edit in the Diagnosis section.

A text bar will appear where you can add a ICD-10 code or description. Options will appear as you type in the text. Select the correct ICD-10 diagnosis code and description. Once you click the  Save button, the diagnosis will be added to the client's chart. 

Changes to a client's diagnosis will be logged in the client's Summary tab. You will also have the ability to change the client’s diagnosis from a session notes page.

Changing a Diagnosis for a Particular Session

Diagnosis are time-stamped so that if a diagnosis changes over time, each session reflects whatever the diagnosis was at that time. Therefore, if a superbill, claim, or note has a diagnosis that requires a change, you need to go to the note for a particular session in order to change it. From the note, you may change the diagnosis so that any documents associated with that session reflect the changed diagnosis.

Customizing Diagnosis Labels

When adding a diagnosis, you may customize the label to suit your approach and/or add modifiers and other information not present by default in the description.

Adding Non-ICD Diagnosis

We can support a general "(other)" diagnosis code. When used, you'll be required to add a custom description.

These custom diagnosis codes will be suppressed from all superbills and claims since we have no method to check their validity. If you want a diagnosis code for claims or superbills that isn't listed in our default options, you'll need to contact us at support@sessionshealth.com to add it.

Step 1.

Search for other as a diagnosis.

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Step 2.

Enter your description.

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Creating a treatment plan

Within a client's Diagnosis & Treatment tab, click the Add Treatment Plan button. You are then presented with two treatment plan options. The Default option offers a standard approach to treatment plans, whereas the Simple option provides a simple text box for your to record your treatment plan.

Creating a standard (Default) treatment plan

The standard treatment plan will allow you to add presenting problems, behavioral definitions, treatment frequency and duration, and add goals with objectives.

  • Presenting Problems: Record what problems led the client to seek treatment.
  • Behavior Definitions: Record how have the problems above been affecting your client's day to day life.
  • Treatment Frequency: A recommendation for frequency of client sessions.
  • Treatment Duration: A recommendation for how long the client should receive treatment.
  • Goals: General statements of what the client wishes to accomplish through treatment. You may establish multiple goals within a treatment plan.
  • Objectives: These are the building blocks of goals, so are smaller and perhaps, more short term. This could be a specific skill or outcome the client is trying to achieve. You may setup multiple objectives within a goal.
  • Interventions: Techniques or treatment modality the therapist will use during the session in order to accomplish objectives. You may choose from a list of drop-downs or type in your own interventions.

Once you record a goal or objective for one client, those will be saved as options when completing goals and objectives in treatment plans for other clients.

Creating a Custom treatment plan

You may create a custom treatment plan with or without the integrated goals, objectives, and interventions from your Forms & Documents > Forms > My Forms page. See our Creating a custom form article on setting up custom forms. Once a custom form is created, it'll appear as an option in the Form drop-down list.


Creating a Simple treatment plan

When choosing a Simple treatment plan, a text box will appear for your to record your treatment plan in a single text box. This is helpful if you're copying the treatment plan from a different system or location that doesn't conform to our standard treatment plan template.

Activating the treatment plan

Once your treatment plan is complete, click the Activate button. You will then be prompted to sign the treatment plan.

Note: You may share the treatment plan with a client or contact in Draft or Active stage. When shared, the recipient will be able to sign the treatment plan.

When an objective is complete, you may return to the treatment plan and check the box next to the completed objective. The completed date will be recorded in the treatment plan.

Setting up a reminder to update your treatment plan

If you'd like to setup a reminder for yourself to update the treatment plan, click the Setup reminder button in the bottom right corner of the treatment plan. You'll then have the option to select 3 months, 6 months, 1 year, or a custom future date for the reminder. The reminder will appear in the Needs Attention area of your Home page 7 days prior to the reminder date.

Setting a future reminder to review a treatment plan

Downloading or deleting a treatment plan

Once your Treatment Plan is active you can click the "..." menu to Download a PDF of the treatment plan. From the same menu you can select Remove if the treatment plan is no longer needed. If you wish to re-use elements of the treatment plan no longer needed, first click the Update Treatment Plan in the Draft tab before removing the active treatment plan.

Note: For conjoint clients, you will add the diagnosis and treatment plan to the chart for the conjoint client.

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Recording progress towards objectives

Once a treatment plan is activated, the objectives will be listed when you're completing a client's progress note in each appointment. You may record the status of the objectives, write additional details, and list any applicable interventions.

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Updating a treatment plan

To update a treatment plan, click on the Draft tab of the treatment plan and click the Update Treatment Plan button.

Update a Treatment Plan

The currently active treatment plan will be pre-loaded for you to edit. Once you activate the new treatment plan, the Active version will be marked as complete and will be stored in the Past tab.

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ICD-10 and DSM-V

Sessions Health uses ICD-10 codes and descriptors in our system. Since ICD-10 is currently the standard for medical billing, we adopted ICD-10. 

Critiques of ICD-10

Just like with DSM-V, there are critiques of ICD-10. Some practitioners don't like some of the descriptions. Some don't like that it is part of a "medical model." We don't have control over the content of ICD-10 and believe it's best to use the content in a standard way. We do allow practitioners to override descriptions so that they may use their own. We don't require diagnosis or treatment plans on client charts and so for those who don't like ICD-10 for being a medical model of treatment, those parts of the system are optional. When ICD-11 becomes the standard for medical billing in the United States, we will update our system to ICD-11.

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FAQ

Do you offer Wiley Treatment Planner?

Not at this time, but we may offer this or something similar in the future.

Why doesn't my treatment plan show up in the client's progress notes?

A treatment must be activated and include objectives in order to record the status and interventions in your progress notes.

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