Twofold offers a variety of note templates to accommodate the diverse needs of both general clinicians and mental health providers. In addition to the predefined templates listed below, Twofold Health now supports Custom Templates, a powerful feature that allows users to create and personalize their own note formats. Whether you prefer to start from scratch or modify an existing system template, the Custom Templates feature provides flexibility to tailor your documentation style to suit your specific clinical workflow.
Below is a breakdown of the supported predefined templates and their specific uses:
SOAP
The SOAP (Subjective, Objective, Assessment, Plan) template is a widely used format in healthcare. It organizes information into four key sections:
Subjective: Patient’s statements, symptoms, and history.
Objective: Observable data, including physical exam findings and test results.
Assessment: Clinician’s diagnosis or assessment of the patient’s condition.
Plan: Treatment plan, including prescriptions, tests, and follow-up instructions.
SOAP - Assessment and Plan Combined
This variation of the standard SOAP template combines the Assessment and Plan sections into one, simplifying the documentation for clinicians who prefer a more streamlined approach. It’s ideal when the assessment directly informs the treatment plan, allowing you to document them together.
Templates for Mental Health Providers
Mental health providers often require specialized templates that cater to the unique aspects of mental health documentation. Twofold Health supports several templates designed specifically for this purpose:
SOAP for Mental Health
Similar to the standard SOAP template but tailored for mental health contexts. This version emphasizes the psychological and emotional aspects of the patient’s condition, ensuring that mental health providers can accurately document their sessions.
SOAP - Assessment and Plan Combined for Mental Health
This template merges the Assessment and Plan sections, just like the general version, but with a focus on mental health. It’s designed for mental health professionals who prefer to document their assessments and treatment plans in a unified section.
BIRP
The BIRP (Behavior, Intervention, Response, Plan) template is specifically designed for mental health documentation:
Behavior: Describes the patient’s behavior during the session.
Intervention: Details the interventions or therapeutic techniques used.
Response: Documents the patient’s response to the interventions.
Plan: Outlines the next steps in the patient’s treatment plan.
DAP
The DAP (Data, Assessment, Plan) template is another format used in mental health settings:
Data: Captures objective and subjective information from the session.
Assessment: Provides an analysis of the data and the clinician’s interpretation.
Plan: Specifies the treatment plan and any follow-up actions.
Progress
The Progress template is focused on documenting the patient’s ongoing development and response to treatment. It includes the following sections:
Client Presentation: Describes how the patient presents during the session, including their mood, behavior, and any changes since the last session.
Therapeutic Interventions: Details the interventions or techniques used during the session.
Assessment: Provides an evaluation of the patient’s progress and response to the interventions.
Plan: Outlines the next steps in the patient’s treatment, including any adjustments to the therapeutic approach.
Intake
The Intake template is used for initial patient assessments, providing a comprehensive structure for gathering essential information about a new patient. This template includes the following sections:
Identification Information: Basic details about the patient, such as name, age, and contact information.
Reason for Seeking Therapy: The patient’s primary concerns and motivations for seeking therapy.
Psychotherapeutic Goals: The goals the patient hopes to achieve through therapy.
Medical History: A detailed account of the patient’s medical background, including any relevant conditions or treatments.
Psychosocial History: Information about the patient’s social background, relationships, and environmental factors.
Current Status: An assessment of the patient’s current mental and emotional state.
Diagnostic Information: Any diagnoses made during the intake session.
Treatment Plan: The initial plan for therapy, including therapeutic approaches and any recommended interventions.
GIRP Note
The GIRP (Goals, Intervention, Response, Plan) template is a structured format used for psychotherapy documentation, providing a clear and goal-oriented approach:
Goals: Specifies the therapeutic goals or objectives for the session, based on the client's treatment plan or presenting concerns.
Intervention: Details the specific therapeutic techniques, strategies, or interventions applied during the session to address the identified goals.
Response: Documents the client’s reaction, engagement, and progress in response to the interventions used.
Plan: Outlines the next steps, including any adjustments to the treatment plan, future goals, and follow-up actions.
Choosing the Right Template
Selecting the appropriate template is crucial for accurate and effective documentation. Twofold Health’s supported templates are designed to meet the diverse needs of clinicians and mental health providers, ensuring that your notes are structured, comprehensive, and tailored to your practice.
💁♀️Tip: Explore Different Note Types
You can experiment with different note templates by regenerating the same note in various formats. To do so, simply click ‘Change Template’ on the note page, and select a new template to see how the content adapts to different documentation styles.