Mental Health Practitioner Taking Notes on Patient Outcomes

Better Outcomes with Behavioral Health Documentation Software

Behavioral healthcare spans a wide variety of services offered by providers to help their patients. Group therapy, residential care, medical diagnostic procedures, outpatient therapy, and individual counseling sessions are just a few examples of treatment provided by behavioral healthcare specialists. With all the different services in this field, there needs to be a way to centralize the medical records of a patient being seen by various providers.

Electronic medical records (EMRs) have been implemented in various healthcare settings around the world in an effort to improve the care provided to patients. In comparison to paper documentation, EMRs in healthcare have risen to the point where approximately 85% of doctors in an office setting are using some sort of EMR software. Also, documentation software applications that are broadly available in the healthcare field are tailored to providers’ specific needs.

In general, the use of EMR software, including behavioral health documentation software, provides many benefits, including the following.

  • Records That Are Easy to Update and Review
    • Electronic records enable different providers practicing in different locations to upload information about one patient into a centralized file. This improves the ease of access for other healthcare providers and makes it simpler to follow a patient across the duration of their treatment.
  • Convenient Notifications and Reminders
    • Electronic records typically provide options to alert providers when they have patients scheduled or when specific documents require their attention.
  • Increased Efficiency
    • When documenting medical records electronically, there’s no need to transcribe handwritten medical notes. Electronic billing systems are also easier to manage and improve payments and payment processing, which increases the speed at which patients can receive services or prescriptions.
  • Improved Accuracy
    • Electronically typed notes are easier to read than handwritten notes, making it less likely for a misunderstanding to affect patient care.
  • Increased Oversight and Prescription Management
    • Electronic prescriptions ensure accuracy, and those uploaded in a centralized database enable pharmacists to obtain the records too, helping to decrease the potential for drug abuse.
  • Improved Communication
    • With the entire healthcare history of the patient available on a centralized electronic database, providers can easily access the information that they need. This helps prevent providers from performing repetitive, ineffective treatments or procedures with a patient and streamlines their care.

Better Outcomes with Behavioral Health Documentation Software

Other benefits of behavioral health documentation software are more specific to behavioral healthcare practitioners.

Improved Security

Documents filed electronically can be filed more accurately, and electronic files cannot be destroyed in an event such as a fire or flood. The encryption within various behavioral health software products makes it harder for someone to have unauthorized access to patients’ medical records. Providers must authorize specific people to view a patient’s documents. This access is based on HIPAA guidelines, giving the patient control over who gets to see their records.

Improvement in Medication Management

Medications can be an integral part of behavioral healthcare, and the use of electronic behavioral health software can improve the administration and management of a patient’s medications.

  • **Drug Abuse: **Specific medications prone to abuse, like opioids, can be more strictly controlled using electronic records. Broad drug abuse screenings are used in behavioral healthcare, and behavioral health documentation software can be tailored to highlight levels of specific drugs from this testing that can notify a provider of potential abuse or overmedication.
  • Monitoring: Medications that can impact bodily functions may be administered to patients. For example, a patient prescribed antipsychotic medications may also need to have reflex orders put into their file, where specific tests are ordered when a medication is prescribed to monitor their metabolic activity. Behavioral health documentation software can be set up to easily monitor both the prescribed antipsychotic and the associated metabolic testing results.

Available for Quick Access on Any Device

Easy access to medical records is essential for a behavioral health specialist. Behavioral health software can include mobile applications that will provide even quicker access to a patient’s centralized document portal and healthcare history. There are many examples where having this rapid access would be critical to behavioral healthcare providers.

Certain behavioral health conditions have historically included seclusion and restraint as treatments, which can compromise a patient’s trust in their provider. Electronic documentation software can offer providers fast access to files that can show them the de-escalation techniques that have been used on a patient in the past so seclusion and restraint methods can be avoided. Access to these techniques can also be critical in cases where a patient may be exhibiting suicidal ideations.


Another benefit of behavioral health documentation software is the customizability of the available programs. Providers can tailor their electronic software program to meet their specific needs, which can range from medication management and facility management to specific patient care centered on record management. Also, providers can include any standardized or specific patient care documentation needs in their software setup.


Behavioral health software can improve patient care, clinical outcomes, and the efficiency of providers in the field. While there are a few barriers to implementing this software, the primary goal of continually improving patient care can be realized by utilizing the technology that continues to be developed for behavioral healthcare providers.

Here at CarePaths, we help therapists work more effectively and improve patient outcomes by empowering them with the data that they need via EHR. To learn more about how we can help you, start your free trial today!

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