Psychiatry dictation software for evaluations, mental status exams and med management

A psychiatric note is mostly narrative. The history of present illness, the mental status exam and the risk assessment are written in sentences, and they are slow to type well. Dictating them is faster, but a general dictation tool turns "anhedonia" into "and hedonia", "aripiprazole" into three words and "PHQ-9" into a phone number. VoicePrivate carries a Healthcare dictionary with 2,635 psychiatry terms, the largest specialty vocabulary in the app.

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Notes psychiatrists and psychiatric nurse practitioners dictate

Psychiatric diagnostic evaluation

Chief complaint, history of present illness, past psychiatric history, substance use, family and social history, mental status exam, formulation and plan.

Medication management follow up

Interval history, PHQ-9 and GAD-7 scores, side effects, adherence, dose changes and labs such as a lithium level or a metabolic panel for an antipsychotic.

Risk assessment

Suicidal ideation with or without plan or intent, protective factors, access to means, safety plan and level of care.

Inpatient and partial hospital notes

Admission H&P, daily progress notes, discharge summaries and continuity of care after crisis.

Therapy and letters

Progress notes for cognitive behavioral therapy and other modalities, prior authorization letters and letters to the primary care clinician.

Psychiatry words general dictation gets wrong

The Healthcare dictionary stores the mishearings it corrects. A few from the psychiatry list:

• "thot disorder" to thought disorder
• "cyclothymic disoder" to cyclothymic disorder
• "remision" to remission
• "chlorpromazeen" to chlorpromazine and "molindon" to molindone
• "schema therepy" to schema therapy
• "neuropsycholgy" to neuropsychology
• "multi-disciplinary team" to multidisciplinary team

Drug names are matched by sound as well. A misheard "lammatrogen" becomes lamotrigine. A real drug name is never swapped for a different drug, so sertraline stays sertraline.

What choosing Psychiatry / Behavioral Health does

On Mac, open Settings and set the Medical specialty to Psychiatry / Behavioral Health. Recognition is then primed with its core terms: major depressive disorder, generalized anxiety disorder, bipolar disorder, schizophrenia, PTSD, anhedonia, suicidal ideation, PHQ-9, GAD-7, mental status examination, affect, psychosis, hypomania, cognitive behavioral therapy and medications such as sertraline, escitalopram, fluoxetine, venlafaxine, duloxetine, bupropion, mirtazapine, trazodone, lithium, quetiapine, aripiprazole, olanzapine, lamotrigine and esketamine. A long misheard word that is a near miss of one of those terms is matched to it first. On Windows there is no picker and the full medical dictionary is used for every note.

Example: a medication management follow up

Click into each field of the note, press the hotkey, speak, and press the hotkey again. The text is pasted when you stop.

1. Interval history. Press Command+Shift+Space and say: "Thirty four year old with major depressive disorder, recurrent, moderate, and generalized anxiety disorder, seen for follow up 6 weeks after sertraline was increased to 100 milligrams. Mood better, sleep 7 hours, less anhedonia." Press the hotkey again.
2. Scales: press Command+Shift+Space and say: "PHQ-9 9, down from 17. GAD-7 8, down from 14." Press the hotkey again.
3. Mental status exam: press Command+Shift+Space and say: "Casually dressed, good eye contact, speech normal rate and volume. Mood okay, affect mildly constricted, thought process linear, no evidence of psychosis. Denies suicidal ideation, plan or intent." Press the hotkey again.
4. Plan: press Command+Shift+Space and say: "Continue sertraline 100 milligrams daily. Add cognitive behavioral therapy, referral placed. Safety plan reviewed. Return in 8 weeks." Press the hotkey again.

Into your EHR

VoicePrivate pastes through the clipboard and then puts back what you had copied, so there is nothing to install inside the EHR. It works in any text field that accepts a paste: Epic, Oracle Health (Cerner), athenahealth, eClinicalWorks and behavioral health systems such as SimplePractice, TherapyNotes and Valant. If your EHR runs in Citrix or another remote desktop, the session must allow clipboard redirection from your computer. The EHR dictation guide covers each one.

Many psychiatric notes repeat the same sentences, such as a normal mental status exam or a safety plan review. Text shortcuts expand a short phrase into that full paragraph, which you then edit for the patient in front of you.

On-device facts

Speech is processed on the Mac or Windows PC that runs VoicePrivate. Audio never leaves that computer, and nothing is sent to a cloud service for transcription. There is no recording of the session with the patient: you dictate the note yourself after or between visits. With Auto-save transcriptions on, which is the default, each dictation is also kept in the app's Library on that computer. Turn it off in Settings if you want the EHR to hold the only copy.

Price

Healthcare Edition is $297 a year or $34.99 a month per clinician. There is no free trial. Individual monthly and annual plans have a 30-day money-back guarantee on the first payment. Group practices of 2 to 20 clinicians can buy team seats.

Psychiatry dictation FAQ

Psychiatry overlaps with neurology dictation for cognitive and seizure workups. For dictating outside the visit, see dictation for doctors and how on-device dictation compares with an AI medical scribe.