How to Create SOAP and DAP notes using Mentalyc's Dictation Feature

Effortless Session note-taking with Mentalyc's Dictation Feature

Mentalyc has introduced a dictation feature for therapists. With this feature, therapists can easily create a summary of a session by recording their observations and uploading the audio file to the platform. Mentalyc's AI-powered tool can then generate a progress note in either DAP or SOAP format, making the documentation process much simpler and more efficient for therapists. This feature is a game-changer for busy therapists who need to document their sessions quickly and effectively.

Who is it best for?

• Therapists who forgot to record sessions or did not have the client’s consent to record the session.
• Therapists who have sessions that include any number of clients in the session. For example, in group therapy and family play 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?

• Situations where precise session quotes, details, or verbatim transcripts are essential, and you are worried that you might forget such details.
• For individuals with memory or hearing problems, it may be better to have a transcript available for easy reference.

What are the benefits?

1. There is no need to record the session; therapists can dictate a summary or narration to a recording tool or software and Mentalyc will do the rest.
2. It offers a quick and efficient way to take notes without the need for writing or typing.
3. Mentalyc takes care of formatting and structure, allowing therapists to speak naturally and conversationally for an audio journal-like experience.

Steps on how to use the Dictation Feature

1. Step 1: Pick a dictation tool - The first step is to pick a suitable dictation tool to record the session summary. 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.

1. Step 2: Record a clear and concise dictation - Once you have selected the dictation tool, proceed to record a clear and concise dictation of the therapy session on your preferred recording software or device. Your summary should be 1-5 minutes long and include the most important insights and observations.
2. Step 3: Upload the audio file - After recording the dictation, you can upload the audio file to Mentalyc. This can be done easily using the upload feature on the platform. Follow the link for the guide on how to upload a session on your phone or computer.
3. Step 4: Choose a template - Once you have uploaded the audio file, you can select a template for your progress note. Mentalyc offers two templates: Dictated DAP note and Dictated SOAP note. You can choose the one that best suits your needs.

1. Step 5: Select the client - Start writing the client’s name and if you have added them before, their name will show up in the drop-down list. If their name is not there, you can simply go ahead and write the name and click Create “[client name]” and it will be added to the list.

1. Step 6: Select the number of speakers - Next, choose the number of speakers, choose “Dictation” here, and then click “Finish Upload”.

Mentalyc's AI will generate a progress note based on your dictation. The AI will extract relevant information from your summary and create a progress note in either DAP or SOAP format. The resulting progress note will be concise, accurate, and easy to read, saving time and effort.

What to include in the dictation for the best output

• Don't worry about the format, Mentalyc’s AI will adjust it to SOAP or DAP format. Keep in mind that more relevant content produces a better note.
• Describe the main themes, topic, and type of therapy (group, couple, or individual).
• Mention the client's symptoms including when they started, how long they have been going on, how often they occur, how severe they are, and any impairments to demonstrate medical necessity.
• Include interventions and homework suggestions, using the correct names and treatment modalities (theoretical orientation) to showcase evidence-based methods.
• Provide a therapy progress overview, the client's gains and ongoing struggles, and why more sessions are necessary for insurance.

Important: These tips are important for an insurance complaint note. If you do not take any insurance and prefer different information in your note, feel free to test it out and please share your feedback!

Examples of Generated Notes

Below are examples of SOAP notes generated from dictation. The first one provides sufficient information for the AI to work with, while the second one lacks the necessary details.

Below is an example of a SOAP note with missing information. You will get a <missing information> text if enough information is dictated. But no worries, you can always add the missing information after the note has been generated.

Conclusion

By following these steps and including relevant information, therapists can effectively use Mentalyc's dictation feature to streamline their workflow and improve their note-taking process. If you need any further support or have any questions, please don't hesitate to contact us.