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DOCUSISTANT™
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Docusistant — MH/SUD Note (Structured MSE & ASAM, ICD-10 + SDOH preserved)
Docusistant
Administrative
Date of Service (default today)
Setting / Place of Service
11 — Office
02 — Telehealth
12 — Home
03 — School
99 — Other
Telehealth Consent
Not recorded
Consent verified
Clinician Name and Credentials
Start Time
Set Now
End Time
Set Now
Total Minutes (auto)
Primary reason for visit
Mental Health
Substance Use Disorder
Both
New vs Existing
New
Existing
Exacerbated by stressors?
No
Yes
Diagnosis & SDOH
ICD-10-CM Category
Specific ICD-10-CM Code
Select a Stressor
Additional Stressors (free text)
Mental Health
Diagnosis status
Unchanged
Improved
Worsened
Onset
Severity
Mild
Moderate
Severe
Triggers
Impact
What helps
Risk
Impacted Domains
Work/School
ADL
Social/Family
Legal
Mental Status Exam (MSE)
General appearance
well-groomed
adequately groomed
disheveled
unkempt
Dress
appropriate
casual
inappropriate to context
Orientation
oriented ×3
oriented ×2
not fully oriented
Motor activity
normal
psychomotor retardation
psychomotor agitation
Speech (rate/volume/tone)
normal rate and tone
rapid/pressured
slow/soft
loud
monotone
Mood (client words)
“okay”
“anxious”
“down”
“irritable”
“better”
Affect
congruent
incongruent
restricted
flat
labile
Thought process
logical
goal-directed
circumstantial
tangential
flight of ideas
Thought content
within normal limits
rumination/obsessions
delusional content
SI without plan
SI with plan
HI/violent ideation
Perceptions
intact
illusions
auditory hallucinations
visual hallucinations
Attention/Concentration
good
fair
poor
Memory
intact
impaired
Insight
good
fair
poor
Judgment
good
fair
poor
Impulse control
intact
impaired
Overall functional status
intact
mildly impaired
moderately impaired
severely impaired
Substance Use Disorder (SUD)
SUD Diagnosis Category (separate SUD list)
— Select —
F10 — Alcohol-related
F11 — Opioid-related
F12 — Cannabis-related
F13 — Sedative/hypnotic
F14 — Cocaine-related
F15 — Other stimulant
F16 — Hallucinogen-related
F18 — Inhalant-related
F19 — Multiple/other
SUD Specific ICD-10 Code (keep exactly what you use)
— Select a category first —
Diagnosis status
Unchanged
Improved
Worsened
Onset
Triggers
Impact
What helps
Risk
Severity
Mild
Moderate
Severe
Impacted Domains
Work/School
ADL
Social/Family
Legal
ASAM Dimensions (1–6)
Dim 1 — Acute Intoxication/Withdrawal
not experiencing withdrawal
experiencing mild withdrawal
experiencing moderate withdrawal
experiencing severe withdrawal
Dim 2 — Biomedical
no significant medical issues
medical concerns present
Dim 3 — Emotional/Behavioral/Cognitive
stable with manageable symptoms
active psychiatric symptoms
significant cognitive/behavioral complications
Dim 4 — Readiness to Change
highly motivated
ambivalent
resistant
Dim 5 — Relapse/Continued Use Risk
low
moderate
high
Dim 6 — Recovery/Living Environment
supportive
unstable
harmful
Psychotherapy
Individual Psychotherapy?
No
Yes
Psychotherapy Minutes (optional, auto from time if empty)
Techniques Used (check any)
Cognitive Challenging
Cognitive Refocusing
Cognitive Reframing
Communication Skills
Compliance Issues
DBT
Exploration of Coping Patterns
Exploration of Emotions
Exploration of Relationship Patterns
Guided Imagery
Interactive Feedback
Interpersonal Resolutions
Mindfulness Training
Preventative Services
Psycho-Education
Relaxation/Deep Breathing
Review of Treatment Plan/Progress
Role-Play/Behavioral Rehearsal
Structured Problem Solving
Supportive Reflection
Symptom Management
Client Engagement
Fully engaged
Distracted
Resistant
Observed Response (check any)
Tearful
calm/relaxed
participated actively
requested support
required redirection
Insight/skills
Strong insight; skills applied
Emerging insight; partial uptake
Limited insight; minimal uptake
Impacted Domains
Work/School
ADL
Social/Family
Legal
Functional Status
Improved
Unchanged
Worsened
Treatment Planning
Reviewed/Updated?
No
Yes
Type
Initial
Interim Update
Period Review
Frequency
Weekly
Biweekly
Monthly
Level of Care
Outpatient
IOP
PHP
In-Patient
Progress
Improved
Unchanged
Worsened
Goals Addressed
Anxiety
Depression
Work/School
Relationships
Substance Use
Sleep
Goals (free text)
Planned Services
Psychotherapy
Skill Training
Case Management
Medication Management
Group Therapy
Planned Services (free text)
Final Note
Generate Final Note
Clear Form