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About Upheal's own progress notes

Understanding the layout, sections, and value our progress notes provide.

Aviva Glassman avatar
Written by Aviva Glassman
Updated over a week ago

By listening to the preferences of our users, we’ve developed the Upheal note type. Our own default progress notes are organized into Client Presentation, Therapeutic Interventions, Assessment, and Plan sections.

We also offer several other AI-supported note types, and you can easily change your note type.

Upheal notes sections

Client Presentation

Upheal's AI will identify information from your session related to the client’s mood, openness, speech, and the problems they’re dealing with, and present it in an objective way. You can add, edit, format, or delete parts of this section as needed if you have additional observations that the AI didn’t catch from verbal communication.

Therapeutic Interventions

The AI is also trained to remember all the interventions you suggested when in session and captures them as a list in this section for you. This includes all the important suggestions and healing strategies you discussed, presented in an objective way. You can also add, edit, format, or delete parts of this section as needed.

The Therapeutic Interventions section reflects clinical criteria based on the EEMM model. The EEMM is a meta-model of diagnostic and intervention approaches that can accommodate any set of evidence-based change processes, regardless of the specific therapy orientation. The types of interventions we cover include:

  1. Affective interventions: Exposure, experiential avoidance, acceptance-based interventions

  2. Cognitive interventions: Defusing work, cognitive restructuring, etc.

  3. Attentional interventions: Mindfulness, present-moment awareness, and somatic techniques

  4. Self-based interventions: Perspective-taking, self-as-context, and parts or systems work

  5. Behavioral modification interventions

  6. Motivational and values-based interventions

Assessment

The Assessment section of your notes is the synthesis of what our AI model thinks the client's problem might be. It will be formatted as a narrative. For example, "Client is struggling with unresolved grief and guilt associated with the death of his father and the death of his patient during surgery." Our AI exists to help you save time not replace your wisdom or experience, so as with the other sections, you may add, edit, format, or delete parts of the Assessment.


Plan

In the Plan section, you'll find a bullet list of any next steps you may have discussed in your client session. This may even include the "homework" that you set for the client. However, we recommend going through this section more carefully to add plans based on your experience and intuition since the AI captures only what's verbally discussed in a session. There may be techniques and ideas you'll want to try that you will not have time or the desire to discuss in a session.

For example:

  • Work on strategies to move from one pie chart to the other in upcoming sessions.

  • Talk to the client’s brother about going into therapy with the client.

  • Continue to provide psychoeducation about the unique nature of therapy.

If you want Upheal's powerful AI to help you develop long-term strategies for your clients, check out our Treatment Plans.

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