Stop dreading documentation: Save time with AI progress notes
Become a more efficient therapist with secure AI progress notes, specifically designed for mental health professionals.
Save 6 hours per week on average
What would you do with six extra hours each week? With less time spent on admin, you can take on more clients or enjoy some well-deserved relaxation time.
Struggling to split attention between your clients and detailed note-taking? AI notes let you focus on the client without worrying you'll miss important details.
With manual note-taking distractions a distant memory, you can stay present during sessions and provide a more engaging client experience every session.
Upheal progress note
Client presentation
Therapeutic interventions
Assessment (Risk, MSE)
Plan
Progress note generated by Upheal AI without any additional modifications. Sign up for free to try it yourself.
SOAP note
Subjective
Objective (MSE)
Assessment (Risk)
Plan
Progress note generated by Upheal AI without any additional modifications. Sign up for free to try it yourself.
DAP note
Data
Assessment (Risk)
MSE
Plan
Progress note generated by Upheal AI without any additional modifications. Sign up for free to try it yourself.
GIRP note
Goal
Interventions
Response
Plan
Assessment (Risk)
Progress note generated by Upheal AI without any additional modifications. Sign up for free to try it yourself.
BIRP note
Behavior
Interventions
Response
Plan
Assessment (Risk)
Progress note generated by Upheal AI without any additional modifications. Sign up for free to try it yourself.
EMDR note
Client information
Presenting issues and preparation
Assessment
Desensitization
Installation
Body scan
Closure
Reevaluation and next steps
Progress note generated by Upheal AI without any additional modifications. Sign up for free to try it yourself.
Mental Status Exam
Appearance
Behavior
Speech
Mood
Affect
Thought content & process
Cognition
Insight
Judgment
Progress note generated by Upheal AI without any additional modifications. Sign up for free to try it yourself.
Headway SOAP
Subjective
Objective (MSE)
Assessment (Risk)
Plan
Progress note generated by Upheal AI without any additional modifications. Sign up for free to try it yourself.
Intake note
Identification information
Reason for seeking therapy
Psychotherapeutic goals
Medical history
Psychosocial history
Current status
Diagnostic information
Treatment plan
Progress note generated by Upheal AI without any additional modifications. Sign up for free to try it yourself.
BPS Intake assessment
Reason for Treatment
Psychological Factors
Biological Factors
Social Factors
MSE
Risk Assessment
Summary of Risk Factors
Assessment Summary
Progress note generated by Upheal AI without any additional modifications. Sign up for free to try it yourself.
Our own unique progress notes include the Client presentation, Therapeutic interventions, Assessment (including risk and MSE), and Plan sections. Our AI has been specially trained in collaboration with mental health experts.
Upheal progress note
Client presentation
Therapeutic interventions
Assessment (Risk, MSE)
Plan
Progress note generated by Upheal AI without any additional modifications. Sign up for free to try it yourself.
Subjective, Objective, Assessment, and Plan. Track the client’s progress, thoughts, behavioral changes, subjective experiences, and facilitate therapeutic insights as well as enable effective session planning.
SOAP note
Subjective
Objective (MSE)
Assessment (Risk)
Plan
Progress note generated by Upheal AI without any additional modifications. Sign up for free to try it yourself.
Data, Assessment, and Plan. A note style that combines subjective and objective data into one section and primarily focuses on the client’s goals and the interventions used to address them.
DAP note
Data
Assessment (Risk)
MSE
Plan
Progress note generated by Upheal AI without any additional modifications. Sign up for free to try it yourself.
Goals, Intervention, Response, and Plan. Focuses on the specific goals and objectives identified by the client for therapy, outlines therapeutic interventions and techniques used, evaluates their effectiveness, and facilitates planning for continued growth.
GIRP note
Goal
Interventions
Response
Plan
Assessment (Risk)
Progress note generated by Upheal AI without any additional modifications. Sign up for free to try it yourself.
Behavior, Intervention, Response and Plan. BIRP notes include the subjective and objective data from your session in one place, the behavior section. They are especially useful in the behavioral health field.
BIRP note
Behavior
Interventions
Response
Plan
Assessment (Risk)
Progress note generated by Upheal AI without any additional modifications. Sign up for free to try it yourself.
Eye Movement Desensitisation and Reprocessing. Measure the client’s emotional and physical responses, shifts in beliefs or perceptions, and insights that arise when dealing with traumatic memories. Emotions are rated and located in the body, followed by bilateral stimulation and de-sensitization.
EMDR note
Client information
Presenting issues and preparation
Assessment
Desensitization
Installation
Body scan
Closure
Reevaluation and next steps
Progress note generated by Upheal AI without any additional modifications. Sign up for free to try it yourself.
The MSE is a standard tool used by clinicians to assess the basic functioning of a client. The assessment categories include mood, cognition, perception, thoughts, behaviors, insight, and judgement.
Mental Status Exam
Appearance
Behavior
Speech
Mood
Affect
Thought content & process
Cognition
Insight
Judgment
Progress note generated by Upheal AI without any additional modifications. Sign up for free to try it yourself.
A SOAP template aligned with Headway's note structure, capturing clinical summaries, diagnostic support statements, medical necessity, and progress toward treatment objectives.
Headway SOAP
Subjective
Objective (MSE)
Assessment (Risk)
Plan
Progress note generated by Upheal AI without any additional modifications. Sign up for free to try it yourself.
Use Intake notes during an intake session to automatically capture answers to standard intake questions such as personal and social history, family background, and any previous treatment received.
Intake note
Identification information
Reason for seeking therapy
Psychotherapeutic goals
Medical history
Psychosocial history
Current status
Diagnostic information
Treatment plan
Progress note generated by Upheal AI without any additional modifications. Sign up for free to try it yourself.
A comprehensive assessment to inform diagnosis and guide individualized treatment planning. Captures the client’s main concerns, symptoms, and reasons for seeking treatment, alongside psychological, biological, and social factors influencing the client’s wellbeing.
BPS intake assessment
Reason for Treatment
Psychological Factors
Biological Factors
Social Factors
MSE
Risk Assessment
Summary of Risk Factors
Assessment Summary
Progress note generated by Upheal AI without any additional modifications. Sign up for free to try it yourself.
Psychiatric SOAP note
Subjective
Objective (MSE)
Psychiatric review of systems
Medication management
Dosages & side effects
Substances
Assessment (including Risk)
Plan
Progress note generated by Upheal AI without any additional modifications. Sign up for free to try it yourself.
Psychiatric Intake note
CC
HPI
Psychiatric review of systems
DSM-V
Past medical & psychiatric history
Medications & substances
Social & family history
Assessment (including Risk)
MSE
Plan
Progress note generated by Upheal AI without any additional modifications. Sign up for free to try it yourself.
Includes important MSE criteria under the Objective section to capture Appearance, Emotions, Thoughts, Cognition, Judgment and Insight. It will identify and spell check medication names, capture dosages, changes, side-effects, and also contains a lab results and risk assessment section.
Psychiatric SOAP note
Subjective
Objective (MSE)
Psychiatric review of systems
Medication management
Dosages & side effects
Substances
Assessment (including Risk)
Plan
Progress note generated by Upheal AI without any additional modifications. Sign up for free to try it yourself.
Use during an initial patient evaluation for a complete psychiatric assessment. Captures chief complaints, mental status, family/social backgrounds, medical and substance histories, and DSM diagnoses leading to an informed treatment plan.
Psychiatric Intake note
CC
HPI
Psychiatric review of systems
DSM-V
Past medical & psychiatric history
Medications & substances
Social & family history
Assessment (including Risk)
MSE
Plan
Progress note generated by Upheal AI without any additional modifications. Sign up for free to try it yourself.
Medical SOAP note
Patient-reported symptoms
Observations & test results
Diagnosis & evaluation
Plan
Follow-up
Progress note generated by Upheal AI without any additional modifications. Sign up for free to try it yourself.
Our Medical SOAP notes include the Subjective (patient-reported symptoms and histories), Objective (observations, measurements and test results discussed), Assessment (diagnosis and evaluation), and Plan (treatment and follow-up) sections.
Medical SOAP note
Patient-reported symptoms
Observations & test results
Diagnosis & evaluation
Plan
Follow-up
Progress note generated by Upheal AI without any additional modifications. Sign up for free to try it yourself.
Our AI system is specifically trained for therapeutic and psychiatric sessions, unlike universal AI solutions like ChatGPT. Create progress notes easily with AI built for you.
AI-powered treatment plans let you generate unique SMART objectives and goals with ease. Plans are flexible, easy to edit, and designed to fit insurance requirements.
Upheal works with a secure infrastructure provider and follows strict security guidelines, complying with HIPAA, PHIPA, PHIPEDA, GDPR, SOC2, and other regulations.
Capture online sessions without leaving your EHR with our browser extension. Record in-person audio or upload recordings, and easily copy and paste notes to your EHR.
Create custom instructions to save time on note edits: shorten sections, convert paragraphs into lists, anonymize information, or translate notes into another language.
Suggested diagnoses and symptoms are generated for review to be included in progress notes and treatment plans. You can also edit and manually add new symptoms.
Want to create your own progress note template? With custom note templates, you can rearrange existing content sections to fit your unique style of progress note.
Brief, accurate summaries of your sessions written in client-friendly language that are perfect for sharing with your clients and helping them stay mindful of their progress.
Capture therapy sessions held in English Spanish, Portuguese, German, French, Italian, Mandarin, and Hindi. Translate your notes from English with Smart edit.
Yes. AI progress notes complement the work of mental health professionals allowing them to focus on the human aspects of intervention; being attuned and present. In addition, Upheal works with a secure infrastructure provider and according to strict security and privacy guidelines that are continuously monitored and updated according to HIPAA, PHIPA, PHIPEDA, GDPR, SOC2, and other regulations. More about privacy and data security.
Yes, we do. Upheal handles sensitive personal information so mental health professionals need to collect client consent before holding sessions. You can use our consent collection template and delegate consent collection to us. Any client whose data enters Upheal must agree to this, even if you only use the audio recorder or upload recordings from sessions held in person or on other platforms. We take privacy very seriously. More about consent here.
Yes, you can create session notes for free with Upheal. While we start you out on a 14-day trial of our most advanced paid plan, our Free plan still lets you generate notes — as many as you want, for as long as you want. We don’t rush you to adopt technology before you’re comfortable, despite AI processing costs being high. And if you’re enjoying Upheal, you can earn bonuses and get discounts for other providers with our referral program. More about referrals here. ‍
Absolutely. You can capture online sessions without even leaving your EHR. Our extension works with any telehealth or video-calling platform. You can also capture audio during in-person sessions or choose to upload audio recordings manually. Either way, it’s easy to copy-paste the note content to your EHR.
No, we are not. Our goal is to support the therapist in the work that they do and provide better life balance with AI-powered automation. We do a limited amount of data training for specific scenarios like medication and name recognition, prompt evaluation, or to test the accuracy of our notes. Clients have the option to participate or decline in the sharing of their data for improvements to the Upheal app. Read more.
We respect the ethics of the therapy process, including following strict privacy protocols. Though we need to process private session content to be able to create customized and insurance-ready notes, we delete all audio recordings by default and have several organizational, infrastructural, and technical layers of protection. We follow the best security and privacy principles set by the SOC2 framework and have passed certification by an independent auditor. More about privacy here.
The first AI-assisted platform for mental health professionals with progress notes and analytics.
