SimplePractice Clinical Notes & Documentation Assistant
Generate HIPAA-compliant clinical notes for SimplePractice with treatment plans and billing codes
What You Can Do
You can rapidly generate comprehensive, legally defensible clinical documentation for SimplePractice that meets compliance standards and includes treatment planning and billing code verification. The skill transforms session details into structured progress notes, treatment plans, and risk assessments while automatically cross-referencing appropriate ICD-10 and CPT codes. You save hours on documentation while ensuring clinical accuracy and regulatory compliance.
Features
Creates structured notes following SimplePractice documentation requirements with customizable clinical templates
Drafts comprehensive treatment plans with measurable goals, therapeutic modalities, and session frequency recommendations
Suggests and validates ICD-10 diagnoses and CPT procedure codes aligned with documented clinical activity
Reviews generated notes for privacy violations, unnecessary identifiers, and legal documentation standards
Generates suicide/harm risk assessments and safety planning documentation with clinical decision-making rationale
Articulates your clinical reasoning and treatment interventions for each documented session activity
Creates comprehensive discharge summaries with clinical summary, achievements, and aftercare recommendations
Transforms unstructured session notes into formatted clinical documentation ready for SimplePractice import
Example Output
Progress Note Example:
Date: 7/29/2026 | Clinician: Dr. Chen, LCSW
Presenting Concern: Ongoing anxiety related to workplace transitions and family conflict.
Clinical Observations: Improved emotional regulation; normalized speech rate; reported 3 days consistent sleep; negative affect present but manageable.
Interventions Provided:
- Cognitive reframing: Identified 2 catastrophic thinking patterns
- Grounding technique: Taught and practiced 5-4-3-2-1 sensory method
- Homework: Daily mood tracking and anxiety exposure exercise
Clinical Rationale: Client demonstrates readiness for behavioral activation given improved regulation. Continued cognitive restructuring aligns with CBT treatment plan.
Risk Level: Low (SI/HI screened negative) Billing: ICD-10 F41.1, CPT 90834 (50-min therapy)
Treatment Plan Example:
Problem: Generalized Anxiety Disorder (F41.1) Goal: Reduce anxiety 8/10 → 4/10 or lower within 12 weeks Modality: Cognitive-Behavioral Therapy | Frequency: Weekly 50-min Interventions: Cognitive restructuring, exposure hierarchies, mindfulness techniques Progress Indicators: Reduced avoidance, improved sleep, ability to engage in previously avoided activities
What's Included
- SKILL.md: Complete Claude prompt with clinical best practices, SimplePractice schema mapping, and compliance guidelines
- Progress Note Template: Structured format matching SimplePractice documentation fields
- Treatment Plan Template: Goal-oriented format with measurable outcomes and modality selection
- Risk Assessment Workflow: Suicide/harm assessment and safety planning checklist
- Billing Code Reference: Quick-lookup ICD-10 diagnoses and CPT procedure codes by condition
- HIPAA Compliance Checklist: Privacy verification and documentation requirement validation
- Discharge Summary Template: Comprehensive case closure documentation format
Who It's For
- Licensed therapists & counselors — LCSW, LMFT, LPC managing high-volume caseloads
- Psychiatrists & nurse practitioners — Prescribers documenting medication rationale and clinical decisions
- Clinical psychologists — Psychologists writing assessments and clinical formulations
- Substance abuse counselors — Addiction specialists documenting treatment progress and relapse prevention
- Crisis & trauma specialists — Clinicians developing safety plans and risk mitigation strategies
Best For
- Daily progress note writing — Convert session details into compliant notes in 5-10 minutes
- Treatment plan development — Create goal-oriented plans aligned with clinical presentation
- Billing code selection — Verify ICD-10 and CPT codes before insurance submission
- Risk assessment documentation — Generate thorough suicide/harm assessments with clinical rationale
- Discharge planning — Produce comprehensive closing documentation when cases terminate
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