Reduce Behavioral Health Charting Time with AI-Powered Documentation

Auto-population reduces charting time by automatically pulling patient data from demographics, appointments, prior progress notes, problem lists, medications, treatment plans, admissions, and patient history directly into clinical forms—eliminating the need to retype the same information across multiple documents. Configure fields for unidirectional transfer (data flows one way) or bidirectional transfer (data syncs both ways) to minimize manual re-entry while maintaining clinical accuracy. Clinicians spend time on clinical assessment and treatment planning rather than transcribing duplicate information. This automation reduces documentation time by up to 50%, allowing therapists to see more clients or spend more time on direct patient care instead of paperwork.

You don't need IT staff or developers because we build all custom forms for you. Our team has created 10,000+ custom forms for behavioral health practices using our proprietary form builder. We handle the complex setup required to ensure every field is reportable, connects to billing rules, supports automated workflows, and meets compliance requirements. Simply request custom forms based on your workflows, and we deliver them within 24-48 hours—fully configured and ready to use. The result: highly automated workflows that trigger reminders and tasks based on clinical data, unique reporting capabilities from any form field, and automated billing that captures charges directly from clinical documentation without duplicate entry.

Golden thread documentation ensures compliance by automatically tracking treatment continuity from initial assessment through discharge. The system creates required connections: diagnoses automatically link to treatment plan goals, treatment plans connect to progress notes showing interventions, and progress notes link to measurable outcomes. Automated alerts identify documentation gaps before audits—missing assessments, overdue treatment plan reviews, progress notes lacking goal references, or interventions without corresponding diagnoses. This continuous monitoring ensures your clinical documentation meets state licensing requirements, accreditation standards (CARF, Joint Commission), Medicaid and Medicare rules, and managed care payer requirements for golden thread compliance. Auditors see complete, connected documentation that demonstrates medical necessity and appropriate level of care throughout the client's treatment journey.

This EHR supports all behavioral health treatment settings and program types: outpatient therapy (individual, group, family counseling), residential treatment facilities, addiction treatment centers and detox programs, psychiatric hospitals and inpatient mental health units, partial hospitalization programs (PHP), intensive outpatient programs (IOP), medication-assisted treatment (MAT) for opioid and substance use disorders, community mental health centers, crisis intervention services, school-based mental health programs, and integrated care organizations providing co-occurring disorder treatment. Customize clinical forms and documentation workflows for each program's specific requirements. The platform supports specialized clinical frameworks including ASAM criteria for addiction treatment level of care placement, NANDA-I standardized nursing diagnoses for psychiatric inpatient care, CARF accreditation standards, person-centered treatment planning, trauma-informed care documentation, and evidence-based practice protocols. Whether you operate a single outpatient clinic or a multi-site organization with diverse programs, the system adapts to your service mix.

Yes. Our AI Documentation Assistant reduces therapist charting time by 40-60% by serving as a real-time clinical scribe during therapy sessions or using ambient listening technology to automatically capture session content and draft progress notes. Clinicians speak naturally during appointments while AI records, transcribes, and organizes clinical information into structured progress note templates. Therapists then review, edit, and finalize the AI-generated documentation to ensure clinical accuracy and compliance with HIPAA and state regulations. The AI learns your documentation style over time, improving accuracy with continued use. Additionally, our AI-powered document management system automatically indexes uploaded files, categorizes scanned documents by type (intake forms, assessments, treatment plans, insurance cards), extracts key clinical information and patient identifiers, and files everything to the correct patient chart—eliminating manual sorting and data entry for administrative staff.

The EHR includes evidence-based behavioral health screening instruments and standardized assessments with automatic scoring, trend analysis, and outcome tracking. Pre-built assessments include PHQ-9 (depression screening), GAD-7 (anxiety screening), CAMS (Collaborative Assessment and Management of Suicidality), Columbia Suicide Severity Rating Scale (CSSRS or C-SSRS), PCL-5 (PTSD screening), AUDIT and DAST (substance use screening), CAGE-AID, ACE questionnaire (adverse childhood experiences), and other validated mental health and substance use disorder assessment tools. All assessments feature automatic scoring that calculates results instantly, eliminating manual calculation errors. Track assessment results longitudinally over time to measure symptom severity changes, treatment effectiveness, and client progress toward recovery goals. Customizable flowsheets visualize any assessment data point graphically, enabling clinicians to identify patterns, track medication response, and make data-driven treatment decisions. Request custom assessments built to your specifications within 24 hours.

This EHR includes fully integrated billing—no separate billing software required. Clinical documentation automatically connects to billing workflows, so every progress note, assessment, and treatment plan links directly to charge capture, fee schedules, claim generation, and authorization tracking. The system handles complete revenue cycle management including electronic claims submission, ERA processing, eligibility verification, claim status tracking, denial management, and patient responsibility calculations. Clinicians document once and billing happens automatically based on the clinical data, eliminating duplicate entry between clinical and billing systems.