Manual Index
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Chapters
The Manual is divided into seven chapters. Click a chapter title to display that chapter's table of contents in the area below.
Chapter Three
A Client Chart
PSYBooks Manual
Chapter Three
Add Notes > Intake Note
What this isThe Intake Note is a form you may wish to use with new clients. It's designed to be flexible, allowing you to write an open-ended intake note or use the more structured format.What it looks likeThe Intake Note is accessed here:  |
Where this isOpen a client's chart by clicking their name in the table on the Charts page, then navigate to the Notes section of the chart. The link to the Intake Note is in the Add Notes section on the top right.
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When you first open the Intake Note, it looks like this:
Notice that there are three links at the top of the form which are all closed: Open-Ended Format, Structured Format and Mental Status Exam:
This gives you some flexibility so you can write the kind of intake note you prefer. There is also a checkbox for WNL (Within Normal Limits) which you may check when appropriate to save time. Each of these links will be discussed below:
Intake Note > Open-Ended Format
Clicking the Open-Ended Format link opens this section:
The Open-Ended section of the Intake Form provides a large textarea where you can write anything you'd like. However, notice that even though this is an open-ended format, it's part of the Intake Note which is always a Medical Record note. If you want to create open-ended intake notes for your own personal use (i.e., that are not part of the Medical Record), use the Open-Ended note type in the Add Note section that's specifically listed as a Psychotherapy Note.
Intake Note > Structured Format
The Structured Format section of the Intake Form looks like this:
This section is actually a blend of a structured form and an open-ended one. The "structure" is that you're given some common types of items that are often covered in mental health intake sessions (e.g., Identifying Information, Presenting Problem, Developmental, Psychosocial, and Sociocultural History, etc.) However, there are textboxes beside each, allowing you to write whatever you want.
Intake Note > Mental Status Exam
The final link at the top of the Intake Form is for the Mental Status Exam. Clicking that link opens a Mental Status Exam on the Intake Form, making it easy to access. Notice that filling out the MSE here makes it part of the Intake Note and does not list it as a separate note on the client's Note tab. Checking the WNL limits checkbox, will submit these values:
Intake Note > Safety Issues
The Safety Issues section is closed when the option in the select box is None. However, if you change the option to anything else, you'll see the extra form fields below:
Diagnoses
The Diagnoses section of the Intake Form looks like this:
You'll be able to choose among existing diagnoses that are already in your Libraries > Diagnosis section or you can also add new diagnoses, both ICD and DSM, right from this section of the Intake Form.
How the Intake Form is displayed on the Notes page
Since the Intake Form is long, it's displayed on the chart's Notes tab as a closed link like this:
You can open it to read by clicking the Intake Form link or the Edit Note tool on the right.