The Behavioral Health note type is designed to help psychiatry and behavioral health clinicians document nuanced conversations with clarity and empathy. The note adapts to what was discussed in the visit and only includes sections relevant to the conversation.
What this note type includes
When the Behavioral Health note type is active, your note is structured to capture:
- Structured psychosocial history, including mood, stressors, substance use, and safety
- Medication details, including timing and adherence
- Accurate handling of patient self-diagnosis and phrasing
- A flexible format that only includes sections relevant to what was discussed
Eligible specialties
The Behavioral Health note type is the default for clinicians with one of the following specialties selected in their Abridge account settings:
- Psychiatry (recommended)
- Behavioral Health
- Psychiatry, Pediatric
- Behavioral Health, Pediatric
- Addiction Medicine
To confirm or update your specialty, go to Settings and select Account information.
Note settings requirements
To ensure the Behavioral Health note type generates correctly, confirm the following in Note Settings:
- Key sections are enabled: history of present illness (HPI), physical exam (PE), Results, and assessment and plan (A&P)
- The Mental Status Exam is selected from the Physical Exam template dropdown
Mental Status Exam template
A standard Mental Status Exam (MSE) template is available in the Physical Exam templates dropdown for Psychiatry and Behavioral Health clinicians. The MSE template includes the following system headings:
- Appearance
- Mood
- Thought process
- Thought content
- Orientation
- And additional headings as applicable to the visit
How to switch to a standard note
The Behavioral Health note type is the default for eligible specialties. To revert to the standard note format:
- Open the Clinical Note Type dropdown in the note editor.
- Select Standard.