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AI is already being used in healthcare.
Whether we’re ready for it or not, AI tools are here and rapidly transforming the mental health field.
AI can help in many ways – it can make therapy more accessible and affordable, improve interventions, and train new clinicians (APA, July 2023).
However, the most exciting use case for AI in therapy is its ability to help with that administrative burden most therapists dread after each therapy session: progress notes.
While therapists aren’t paid for session documentation, it’s an essential, yet often unrecognized part of the job.
You’re probably wondering, how do AI-powered therapy notes work? And are they a safe and good choice for you?
The rest of this article will help you understand AI therapy notes and dive into questions regarding their safety and efficacy.
This blog is co-authored by Upheal and Thrizer to give you relevant, expert-led information regarding AI. Upheal is an established AI note-taking tool with strict privacy and security regulations. To receive 50% off Upheal for 3 months, click here, and use the promotion code JOINUPHEAL when you make your purchase. Valid until September 16, 2024.
AI therapy notes are session notes created with the help of AI.
This can be from online or in-person therapy sessions, and helps therapists save time and allow them to focus on their clients.
Instead of having to manually write progress notes after each session, AI notes are created automatically from therapy sessions using natural language processing.
Simply put, Artificial intelligence (AI) means using computers to do tasks that simulate what human intelligence can do. Things like the ability to reason, discover meaning, generalize, or learn from past experience.
When it comes to AI therapy notes, this is done thanks to generative AI models which create original content in response to prompts or requests.
In our case, the original content is the new session documentation or progress notes being created.
The prompts are the instructions given by a particular organization to the generative AI. Upheal, for example, has its own set of highly-developed prompts for AI therapy notes.
The prompts are important for determining the quality of the output. Put a good prompt and information in, get a great AI therapy note out.
Al tools all work a little differently, but most have one thing in common – they create a session transcript. To create the notes, the basic process looks like this:
→ The therapy session audio is captured
→ A transcript is created from the session
→ Notes and analytics are created from the transcript
→ Once the note is created, the audio is deleted
Upheal has a clinical team that works on the quality of the prompts to ensure only the most relevant, insightful, and important ideas are suggested for a clinician’s consideration.
Once the notes are created, it’s important to read and edit them.
No AI is capable of replacing human wisdom and years of emotional, cultural, and social experience.
However, different tools produce different levels of note quality, so it’s good to check out a few.
It may be a surprise, but actually, an AI note doesn't look all that different than what you would create, except it wasn't you who had to create it.
That said, what an AI note looks like may also depend on your AI note-taking tool and the note types it offers.
Some provide a variety of therapy note templates, while others focus on only one note style, such as SOAP, and keep their offering limited.
Here is an example of a SOAP note from a real session created with permission by both the client and therapist for marketing purposes for Upheal:
As you can see from this SOAP template, the AI captured a risk assessment and even an MSE. See the whole note here.
If having variety is important to you, then you might want to consider a tool like Upheal for its many progress note templates. They include SOAP, BIRP, GIRP, DAP, Intake, EMDR, Upheal’s own, and even treatment plans.
Therapy sessions have to be at least temporarily captured for the AI to have the necessary data from which to create progress notes. That can raise questions around client privacy.
This means that generally, the organization that runs the generative AI will have some access to this data and it is important to educate oneself about how and why they work with it.
Different organizations have different policies. Using Upheal as an example, and depending on where you practice, your chosen AI note-taking software should have:
Since the contents of therapy are sensitive personal information, it’s important to look for tools that have strong security and privacy regulations.
Any policies regarding how long data is kept are also important to consider.
Tip: also look into a tool’s flexibility when it comes to session capture, as well as rules for deleting various input materials, whether that’s audio recordings, uploaded files, or notes.
As an example, Upheal allows therapists to pause the AI to give clients the possibility of leaving out extremely sensitive topics from any documentation. In addition, original audio recordings are deleted by default once the notes have been created.
A great question.
Clients will have to consent to the AI tool’s terms of service and privacy policy. The client may be asked to do this by email or during a therapy session and can be prepared for this in advance.
But apart from the initial consent giving and privacy considerations, the AI note-taking tool shouldn’t affect clients’ experience of therapy in a practical sense.
And if anything, AI note-taking can actually increase connection and strengthen the therapeutic alliance.
This is because the therapist can focus entirely on the client during a session.
The AI tool runs imperceptibly in the background offering peace of mind in terms of any data capture. And, the therapist may even be better-rested thanks to time saved on documentation.
It can help combat burnout. It’s no secret that mental health professionals are overworked and the need for providers is increasing. An AI tool can greatly improve work-life balance and help therapists regain some much-needed time for themselves.
It’s useful in clinical decision support. AI can be very validating when it comes to therapy notes. There’s nothing like seeing all the listed interventions from a session to remind a therapist just how much work they are doing. This recognition, even if from an AI perspective, still feels good and it’s helpful for insurance, too.
AI can take on the boring data collection part of the job. When it comes to things like session dates, times, duration, frequency, and even further session planning.
It can increase accuracy and improve writing skills. AI documentation captures the session word for word, removing any chance of misremembering or mistyping what was said as can happen with human error. In addition, the notes often organize, highlight, and summarize important session information eloquently.
AI notes can save a lot of time. The most powerful benefit of using AI notes is that they can be a great starting point – meaning, of course, that you get to edit rather than write from scratch. Upheal saves its users 6-10 hours per week.
It creates insurance-proof notes – some provide more insurance-proof language and since they are automated, ensure that all criteria necessary for insurance are covered.
It’s helpful for neurodivergent therapists. It is a recent discovery from the Upheal community that the neurodivergent therapist benefits greatly when it comes to AI notes. That’s especially true if they struggle with comprehension issues, ADHD, or learning difficulties such as dyslexia.
It improves supervision. It’s a great advantage to have session transcripts to review with your supervisee. This provides a detailed record of what happened that you can go over together and evaluate without disturbing the sacred privacy and connection happening in the course of a therapy session. Added analytics can help the therapist in training see blindspots and improve.
Ethics and biases. Data privacy is one of AI-driven mental healthcare's most significant ethical challenges. Unauthorized access, data breaches, and the risk of patient data being exploited for commercial purposes are all concerns that necessitate stringent safeguards. It’s hard to have complete transparency, clear ownership, accountability, patient privacy, and data fairness just yet.
It doesn’t work for all types of therapy. Not all tools support all therapy types, so make sure you look out for individual, couples, group, or other therapy types relevant to you.
Note-taking becomes automated, not a critical thinking exercise. If you’re a recent graduate, it may be advisable to master note-writing completely before moving on to automating the process. Writing notes is an essential part of critical decision-making relating to your treatment plan and diagnosis process, so you may want to start with an AI note-taking tool after you learn the craft first.
You might primarily use an EHR. It’s best to know if you’ll need a tool that’s compatible with your EHR when searching for your tool of choice. Some create notes from online sessions only, others from in-person sessions, and some create notes even from dictated observations and impressions. Upheal does all of the above.
It’s expensive. It’s another thing to consider when making your decision. Some tools are best for individual practitioners, while others support even large organizations and make it possible for therapists to share cases and documentation safely and easily.
Some AI tools provide more than notes.
Imagine a second, neutral opinion observing important aspects of your clients’ behavior like how fast they speak or how often they speak about the past vs. the future.
Insights are often objective data points measured by the AI tool that you can use as a clinician to better understand and track your client's state and progress.
Upheal measures the following and more:
Upheal measures the client vs. therapist talking ratio which is useful for keeping an eye on the therapeutic alliance.
Speech cadence can be a clue for the mood changes that accompany certain disorders, for example, the mania that comes with bipolar disorder.
Upheal also keeps track of how much of your session your client spent in the past, vs., the future.
It does this by using natural language processing (NLP) as mentioned previously; in simple terms, it identifies and analyzes which tense the client was speaking in.
Best of all, the changing metrics can be seen on a session map, making it possible to connect any topics discussed to any outlier data.
Although these metrics aren’t crucial to the note-taking process, they can be additional, helpful insights that can make a difference in your clients’ healing.
Now that you have some idea of how AI notes work, we hope you feel more comfortable exploring a few tools and trying them out.
If you like to know everything before making a decision, also look at a company’s stance on AI and the future.
It can help you understand how much they value therapists and where they see their product going.
Please remember that using AI in your therapy practice should be an individual choice and is completely up to you.
This blog is co-authored by Upheal and Thrizer to give you relevant, expert-led information regarding AI. Upheal is an established AI note-taking tool with strict privacy and security regulations. To receive 50% off Upheal for 3 months, click here, and use the promotion code JOINUPHEAL when you make your purchase. Valid until September 16, 2024.
You certainly can, and it’s a useful way of deepening client connections while saving time to put back into yourself or your practice. However, you’ll want to familiarize yourself with any privacy and security considerations and make your own choice about using AI.
Every tool is a little different, but here is the basic step-by-step guide:
With Upheal, you’ll be able to find the following: SOAP, DAP, BIRP, GIRP, EMDR, Intake, and MSE progress note templates.
It’s possible, but not recommended. A tool that has strict privacy tools and operates using continuous security protocol simply can’t be compared. Not to mention, ChatGPT is not trained using special clinically valid session data – it combs through everything on the internet to dilute the quality of a note. A tool like Upheal with a dedicated clinical team can vouch for QA when it comes to both the sample data and the prompts.
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This blog post is provided for informational purposes only and is not intended as legal, business, medical, or insurance advice. Laws relating to health insurance and coverage are complex, and their application can vary widely depending on individual circumstances and state laws. Similarly, decisions regarding mental health care should be made with the guidance of qualified health care providers. We strongly recommend consulting with a qualified attorney or legal advisor, insurance representative, and/or medical professional to discuss your specific situation and how the laws apply to you or your situation.
