Mental health practice software: assessments, weekly sessions and notes that stay private

Many practices start with the clinic's existing program, or a diary and printed questionnaires. Then the trouble starts, quietly:

• Reception can read the notes. In many general programs, anyone who opens a patient's file opens every session in it.
• Questionnaires stay on paper. Someone adds up the PHQ-9 by hand, and only the total, if anything, reaches the file.
• The safety plan lives on one computer, with phone numbers nobody has checked since.
• Weekly sessions are booked one by one: ten trips through the diary for ten sessions.

In mental health care, privacy is not a setting added later. It is the first thing the software has to get right.

Agree on this list with your colleagues before comparing programs; it holds on paper too:

This is one patient's path through OPALEVI for mental health centers, in the Psychology and psychiatry department. A business registered as a mental health center sees Session where other clinics see visit, and clinician for doctor. Bold words are the labels on screen.

1. 1

   Book

   Reception or the clinician opens Add appointment, finds or registers the patient, picks the service and the hour, and sees at once whether the clinician is free.

2. 2

   Arrive

   Reception records the arrival and presses Send to the clinician, which puts the patient on the clinician's list without opening anything clinical.

3. 3

   Write the report

   Twelve sections follow the interview, from chief complaints and current emotional state to sleep and eating pattern, therapy goals and check-ups. Each one shows who last wrote it and when.

4. 4

   Examine

   Under Psychological assessment, the Mental state examination marks eleven domains, appearance to judgement, as normal, abnormal or Not assessed; a blank row simply means nothing was recorded.

5. 5

   Note the therapy

   Under Therapy: the Session no., the Therapeutic approach (CBT, psychodynamic, systemic, support, other), goals, interventions and the Next session date.

6. 6

   Plan the next step

   Book a follow-up appointment, under Next steps, opens the calendar for this patient on that next-session date. Payment is taken on the same screen, with Print receipt.

Two plain notes. Session no. is typed by you; the calendar numbers a course on its own, and the two are not linked. And every save that changes something lands in Change history, showing who changed which section, before and after. Nurses and assistants can prepare a session, but the clinical record is the treating clinician's to write.

Under Rating scales sit the PHQ-9 questionnaire and the GAD-7 questionnaire. Each item is answered with one of four buttons, from “not at all” to “nearly every day”, and the panel sums them as you go, showing the answered count and the range beside the total: “3 (9/9 · 0–27)” can never be mistaken for a two-answer total. Clear undoes a wrong choice. Both may be reproduced freely, as the screeners' official site (external link) states, so every item is on screen.

The same section records Mood today (0–10), Anxiety level (0–10), sleep quality, hours of sleep and daily functioning, all entered by the clinician. Once two sessions hold ratings, Mood and anxiety across sessions charts both over this patient's sessions in the department.

Two honest limits. Items, order and scoring are the published ones, and the English wording stays close to the published text; in other languages it is a working translation, not a validated one, so compare it with the validated version before relying on it. And with no patient portal, questionnaires are filled in during the session, not sent ahead.

Keep two papers apart. The clinician's record sits under Risk assessment, headed “A record, not an automatic assessment — the judgement remains the clinician's”: a Safety concern choice, a Psychoactive substances grid (never, in the past, currently) and safety notes.

The patient's paper is Safety plan and treatment plan, which follows the Stanley–Brown steps in their order, written with the patient in their own words:

• warning signs, and things they can do alone to take their mind off it;
• people and places that help, people to ask, professionals to contact, with phones and hours;
• Crisis and emergency numbers, typed for their country: none is filled in for you;
• making their surroundings safer, and what matters most to them;
• Agreed actions (what, who, by when) and a Review date.

Once saved, the Safety and coping plan button prints it on the clinic's letterhead, only the steps you wrote, numbered as they stand. It prints nothing from the risk section and no score, so the patient can show it at home.

Inside a shared clinic, the question is who in the building can read a note. OPALEVI answers in three layers.

Reception and finance

Reception books, records arrivals and takes payments, but reads clinical records only if the clinic ticks Reception may see patients' visit history, which is off in a new clinic. Finance never reads them. The desk's own day is in clinic reception software.

Each department

Record privacy, under Settings → Department setup, offers The whole clinic, The department (its staff, the assigned clinician and administrators) or Only the clinician. Psychology and psychiatry starts at the department when nobody has chosen, so a GP in the same polyclinic does not read therapy notes. A one-department practice gets Automatic or Only the clinician. Administrators can always read, so give that role sparingly. In lists, a closed record keeps its date, department and clinician and shows Restricted.

Each clinician

Doctors may only access their own patients limits each clinician to their caseload. Everyone has a personal login, and roles can be tuned permission by permission or used as the base of your own, such as a social worker.

In Add appointment, a ticked Course of treatment asks for the Days of the week and How many sessions, from two to thirty, and places them all at the first session's hour. A clash refuses the whole course instead of half-booking it. Each session is then an ordinary appointment labelled “Session 3 of 10”, and Stop the course cancels the chosen one and all after it. Physiotherapists use the same tool; see physiotherapy clinic software. When Email the patient a reminder the day before is ticked, it applies to every session of the course, so the patient can be emailed before each one if the file holds an email address.

Registered as a mental health center, a business also gets Groups (group sessions with a roll, a private note per participant and names shown only to clinical staff), Programmes (a treatment programme with goals, key worker and discharge plan) and an incident book for events such as self-harm or a patient leaving without notice, which nursing home software covers too. A private practice runs none of the three.

Try each program on a real patient's week rather than a demo, and ask:

Prices and a team calculator: pricing. A general clinic checklist: how to choose clinic software. The rest of the product: features.

Registering as a mental health center creates the Psychology and psychiatry department, and First steps on the Today screen lists what follows.

1. 1

   Price your services

   Add your services and prices: an initial assessment, a therapy session, a family session.

2. 2

   Set who reads what

   Open Record privacy before the first real note; choose Only the clinician where one therapist's notes should stay theirs.

3. 3

   Bring in the team

   Invite your colleagues with their real roles, so every clinician has a calendar column.

4. 4

   Run one real course

   Book a patient's weekly sessions as a course, fill in a PHQ-9 and print a safety plan.