Home > Help Articles > How to Create Progress Notes from Session Recordings

How to Create Progress Notes from Session Recordings

Notes & Transcripts • 2023-04-08

Transform session recordings into progress notes in minutes

Mentalyc offers a feature that allows therapists to generate progress notes from audio recordings of their therapy sessions. With the use of artificial intelligence (AI), Mentalyc can quickly and accurately process the audio recordings and extract necessary data, making the progress note-taking process more efficient and less time-consuming. Mentalyc offers these four (4) types of progress notes, Couple’s Therapy Notes, EMDR Notes, Basic and Universal Therapy Notes (beta). This is to cater to different therapists' preferences and needs. Mentalyc's recording feature can help streamline your workflow and improve the quality of your progress notes.

Who is it best for?

Therapists who have an audio-recorded session with the client’s consent.
It is best for therapists that engage in individual, EMDR, and couple therapy.
Therapists with ADHD, dyslexia, Carpal Tunnel, and Hearing or Viewing disabilities have found this tool to be life-changing in their progress note-creating process.

What is it not good for?

Not suitable for play/kids’ therapy if the content is too abstract.
Not suitable for family and group therapy. Mentalyc is currently only capable of identifying a maximum of 3 speakers. For family and group therapy, our dictation feature is the perfect fit.

Comparing note types

What are the benefits?

Therapists no longer need to worry about remembering all the session details or taking notes during the session. They can simply record the session and focus on the client.
Mentalyc's AI processes the recording and extracts relevant data to support medical necessity. This helps safeguard therapists against insurance audits and ensures their notes meet the necessary requirements.

Steps to upload a session recording

Step 1: The first step is to pick a suitable recording tool to record the session. You can use your phone voice recorder (Android or iPhone) or any recording app on your phone. Alternatively, you can use the inbuilt or any software on your PC or Mac.

Step 2: Begin recording your session with the client. If it's your first time using the recording feature, make sure to check that the audio is being captured properly. Issues may arise if you use headphones without selecting the correct option, so it's best to double-check.
Step 3: Upload the audio file to Mentalyc either from your mobile phone or from your computer. Here is a detailed guide on uploading a recording to mentalyc.

Note: EMDR notes and Couple Therapy notes are PRO features.

Mentalyc's AI will generate the selected progress note based on the session recording, using the selected template.

What to Discuss with the Client for the Best Output

To get the best results from the AI-generated progress note, there are a few things that should be ensured are covered before and during the recorded therapy session. These include:

Client’s part
- Updates on the client's situation since the last session, including major events or changes.
- Quantify the symptoms as much as possible. Ask about when the symptoms started, how long they have been occurring, how often they occur, and their severity.
- Discuss the impact of the symptoms on the client's daily functioning, including any impairments they are experiencing.
Therapist’s part
- Engage with the client in therapeutic activities or interventions during the session. Mention the names of the techniques applied, as this helps the AI correctly identify theoretical orientations and name techniques.
- Even if the session is primarily talk therapy, it's important to identify the therapeutic approach used (e.g., cognitive-behavioral therapy, psychodynamic therapy) and any specific techniques applied.
Progress update
- Explain how the therapy is benefiting the client, and why continued treatment is necessary. This will ensure that the progress note meets the requirements of medical necessity for insurance purposes.
- Provide a progress overview, highlighting the client's gains and ongoing struggles.

Ensure clear audio quality, as the AI tool depends on the quality of the recording.
Speak clearly and concisely, avoiding unnecessary jargon.
Make sure the recording device or software picks the sounds at a high volume. Record a sample session to make sure the recording device or software can capture the sounds at the distance.
Use proper names instead of pronouns when referring to people or things. This will avoid misattribution.

Note: It's important to mention that if therapists do not include any interventions or activities during the session (e.g., only listening to the client), the intervention section in the progress note generated by Mentalyc may be incomplete or repetitive. To ensure accurate and meaningful progress notes, therapists are advised to engage in therapeutic activities during the session to provide relevant content for the note.

Basic Progress Note Example: Client presentation:

The client is reporting struggles with controlling their anger as a reaction to the behaviors of others. The client would like to learn to control their reactions and communicate differently in order to have healthier relationships.
The problem persists since their teenage years, resulting in yelling and swearing, especially at their family members. The client lives with 5 other people who all manage their emotions the same way leaving the client with no role models for other behavior.
It results in negative consequences in their life such as strained relationships with family members and stress at work.

Therapeutic Intervention

Psycho-educated the client on the difference between an aggressive and assertive communication style.
Role-played conflict situations solved by an assertive style.
Guided the client in visualizing themselves as the person they would like to be and helped define the goals.
Assigned homework: Behavioral experiment where they act differently towards family members, take notes, and report in the next session.
Coached the client to pay attention to their thoughts and how they lead to feeling angry.

Progress Statement

The client is making progress in understanding her triggers for anger and is working on communicating more assertively. However, she still struggles with controlling her temper, therefore more CBT training is required.

Client Response

The client is receptive to the therapist’s suggestions and is committed to working on these goals.

Conclusion

With the help of Mentalyc's recording feature and by discussing important topics with the client, therapists can improve their progress note creation process and streamline their workflow. These steps can lead to more efficient therapy sessions and enhanced patient care.