Diagnosis and Treatment Plans


Videos

Notes, Treatment Plans, and Diagnosis

This Sessions Health tutorial covers creating notes, treatment plans, and diagnosis.

Since this video was made, treatment plans and assessments have changed so that you may share them with clients. You may find see the Sharing Treatment Plans and Assessments video below.

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Sharing Treatment Plans and Assessments

This Sessions Health tutorial teaches you about sharing treatment plans and assessments with clients through the client portal.

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Adding a client's diagnosis

You can manage your client's diagnoses from the Clients > [Client Name] > Diagnosis & Treatment tab. Start by clicking Edit.

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. You may have about the Client's diagnosis determination. 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 Clients > [Client Name] > Summary tab. You will also have the ability to change the client’s diagnosis from a session notes page.

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.

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Creating a treatment plan

Click on "Add Treatment Plan" and you will be presented with a modal to create a Client's treatment plan.

Our interface offers a standard approach to treatment plans; on the first screen, you will be required to enter the following fields:

  1. Presenting Problems - What problems led the Client to seek treatment. (You can add as many presenting problems as you need to)
  2. Behavior Definitions - How have the problems above been affecting your Client's day to day life. (You can add as many behavior definitions as you need to)
  3. Treatment Frequency - A recommendation for frequency of client sessions.

    Screen 2:

    1. Goals - What are you and the Client attempting to accomplish through treatment. (You can add as many goals as you need to)
    2. Objectives - Approaches you will take with your Client to achieve their goals. (You can add as many objectives to a goal as you need to)
      1. Description - A specific skill or outcome you are trying to achieve.
      2. Interventions - The treatment modality you will be using to accomplish the Client objective.

    Once you have finished entering your Treatment Plan you need to activate it in order to start completing objectives. Clicking Activate will present you with another Modal where you will be required to sign the diagnosis change digitally. By typing your full name in this form, you acknowledge that you are providing your name to be used as an electronic representation of your signature and that all information entered is accurate and complete.

Once your Treatment Plan is active you can click the "..." menu to Download a PDF of the treatment plan for sharing with your Client or other interested party. From the same menu you can also "Archive" the treatment plan if it is no longer needed.

The objectives in your treatment plan will be displayed as check-boxes; you can check them off as you complete them, and we will log the date. Once you are finished with a treatment plan, you can create a new one, and it will replace the complete treatment plan. We save every treatment plan on your patient record with the dates it was active.

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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 integrate with it in the future.

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