Modern waiting room with white chairs and plants.

AI Scribe for Psychology

Transcribe Health drafts your progress notes and intake assessments from the session, so the note is waiting for you when the client leaves instead of piling up for the evening.

Start Free Trial View All Specialties

Photo: Amelia Lowell / Unsplash

Psychology documentation, from intake to ongoing care

Most of a psychology practice runs on two kinds of notes. The first is the intake: history, presenting problem, mental status, risk screen, and an initial formulation that sets the direction of care. The second is the ongoing progress note, one per session, which has to show what you did, how the client responded, and where the work goes next. Neither is long, but both have to be accurate, and the progress note has to happen again and again, week after week.

The hard part is the timing. The note is easiest to write while the session is fresh, but that is exactly when you are supposed to be with the client, not at a keyboard. So the notes get pushed to the end of the day, and by the sixth client the details blur. Writing after hours is how a lot of clinicians end up carrying documentation home.

Transcribe Health listens to the session and drafts the note in the format you already use, whether that is SOAP, DAP, or BIRP. It captures the intervention (cognitive restructuring, exposure, a homework review), the client's response, screener scores, and the plan, and it leaves the private narrative out of the record where it belongs. You read the draft, adjust it, and sign. Nothing is filed until you do.

Documentation Challenges in Psychology

1
Writing the progress note after each session without breaking presence during it, since typing while a client talks pulls you out of the room
2
Tracking treatment goals, interventions, and client progress across weeks and months so each note connects to the plan instead of standing alone
3
Keeping notes defensible for insurance and audit while protecting the client's private material, which means recording medical necessity without transcribing the session word for word

How Transcribe Health Helps Psychology

Progress Notes in Your Format

Turns the session into a DAP, SOAP, or BIRP note, with the intervention, the client's response, and the plan for next time in the sections you use.

Treatment Plan Continuity

Carries goals and interventions forward so a note references the plan you set at intake rather than starting from a blank page each week.

Intake and Assessment Write-ups

Drafts the history, presenting problem, and mental status from an intake, and records screener scores like the PHQ-9 or GAD-7 where they belong.

A progress note, captured in real time

An abridged DAP note from a routine CBT session for generalized anxiety, drafted the way you would see it before signing.

Individual therapy · 90834 · CBT for generalized anxiety, session 6

Data

34-year-old client seen for a scheduled 45-minute individual session, sixth of a planned course of CBT for generalized anxiety. Reports a moderate week: worry about work deadlines remained but was more manageable, sleep improved to roughly six hours a night from four. GAD-7 today was 11, down from 15 at intake. Completed the thought record homework for four of seven days. Session focused on cognitive restructuring around the belief "if I make one mistake at work, I'll be fired." Client identified the catastrophizing and all-or-nothing patterns and generated two balanced alternatives. No suicidal or homicidal ideation reported; no safety concerns. Alert, oriented, cooperative, mood anxious with congruent affect.

Assessment

Client is engaged in treatment and showing measurable progress, with the GAD-7 down four points and reported improvement in sleep and daytime worry. Beginning to catch and reframe automatic thoughts in session with prompting, though carrying the skill into the work setting is still inconsistent. Partial homework completion is common at this stage and does not indicate resistance. Presentation remains consistent with generalized anxiety disorder; symptoms are improving on the current plan.

Plan

Continue weekly individual CBT. Homework: daily thought record with a focus on work-related worries, plus one behavioral experiment testing the "one mistake means firing" prediction. Introduce worry-postponement scheduling next session. Continue GAD-7 every two to three sessions to track response. Next appointment in one week. Treatment plan goals reviewed; on track for the current 12-session course, will reassess progress at session 10.

Illustrative example. Not a real patient encounter.

Built for psychotherapy coding and your EHR

Notes capture the session length, the intervention, the client's response, and the medical necessity that back up a psychotherapy code. That is the detail insurers look for on review, and the first thing to slip when the note is written from memory at the end of the day.

CPT

90791Psychiatric diagnostic evaluation (intake), no medical services
90834Individual psychotherapy, 45 minutes
90837Individual psychotherapy, 60 minutes
90847Family or couples psychotherapy with the patient present, 50 minutes
96130Psychological testing evaluation, first hour
96136Psychological test administration and scoring, first 30 minutes

ICD-10

F41.1Generalized anxiety disorder
F32.1Major depressive disorder, single episode, moderate
F43.10Post-traumatic stress disorder, unspecified
F43.23Adjustment disorder with mixed anxiety and depressed mood
F90.9Attention-deficit hyperactivity disorder, unspecified type

Fits the workflow you already have

Drafts drop into the practice systems therapists actually use: SimplePractice, TherapyNotes, and TheraNest, along with the larger EHRs a group practice might run. You get the note type you are working in, an intake evaluation, a progress note, or a testing write-up. The notes stay in your control: you read every draft and decide what goes in the record, and the private material a client shares does not have to be transcribed verbatim to make the note defensible.

Psychology AI scribe questions

Does it understand clinical terminology and note formats?

Yes. It writes in SOAP, DAP, or BIRP, and it captures terms like cognitive restructuring, exposure, mental status, and screener scores such as the PHQ-9 and GAD-7 with correct spelling and the right numbers rather than phonetic guesses.

Can it handle intakes and testing, or only regular sessions?

Both. It drafts the full intake evaluation, history, presenting problem, mental status, and formulation, and for testing it records the instruments administered and the scores. Ongoing sessions become progress notes in your format.

How does it keep confidential session content protected?

The note records what is clinically necessary: the intervention, the client's response, risk screening, and the plan. It does not transcribe the session word for word into the chart, so sensitive narrative the client shares stays out of the record while the note still supports medical necessity. You review and edit every draft before anything is saved.

Will it help with insurance and audit defensibility?

It surfaces the elements payers check on a psychotherapy claim: session length, the specific intervention, the client's response, and the medical necessity tied to the diagnosis and treatment plan. That makes claims easier to support and reduces the odds of a denial for a thin note.

How is client information protected?

All data is encrypted in transit and at rest, handled under a Business Associate Agreement available on every plan, and covered by HIPAA for US practices and PHIPA and PIPEDA for Canadian practices. Psychotherapy notes are kept separate from the general record and stay under your control, so they are not exposed to other clinicians by default.

HIPAA Compliant

Ready to Transform Your Documentation?

Join thousands of healthcare providers who save hours every day with AI-powered medical transcription.

Start Free Trial