Generate Intake Notes (Behavioral Health)

Last updated: Nov 2025

Generate intake notes from a recorded or live session—then review, finalize, and auto-fill your EHR using the Nudge Chrome extension.

Who this helps

• Therapists, psychologists, counselors

• Psychiatrists/PMHNPs documenting new evaluations

• Group practices standardizing first-visit documentation
  
  

What you get

• Structured sections: Presenting Problem, History, MSE, Risk, Dx, Initial Plan

• Baseline measures (e.g., PHQ-9, GAD-7) captured for outcomes tracking

• Redaction + formatting controls (bullets or paragraphs)

• EHR Copilot to map fields accurately (edit-before-save)
  
  

How it works with your EHR

Capture a session in Nudge (or upload audio). Your intake draft appears with standard sections. Open a new intake in your EHR, launch the Nudge extension, pick the client/note type, and confirm the field mapping. No API keys or IT projects required.

Quick example

Adult intake (anxiety + sleep):

• Presenting Problem: panic in crowds; sleep onset delay.

• History: prior CBT; no hospitalizations; family history positive.

• MSE: cooperative, anxious affect, normal speech, intact cognition.

• Risk: denies SI/HI; safety factors noted.

• Dx: GAD (provisional); differentials listed.

• Initial Plan: CBT focus + sleep hygiene; baseline GAD-7 recorded; next visit set.
  
  

Results (2025)

Intake note ready in < 90 seconds after capture.
Teams report 4–6 hrs/week saved on documentation.
Cleaner handoffs to treatment planning.

FAQs

Can I require specific intake fields?
Yes. Admins can mark sections as required (e.g., Risk, MSE, Measures) and enforce completion before export.

Will it include medical necessity language?
Yes. The Assessment/Plan can include justification and continuity phrasing; you can edit before finalizing.

Does it connect to the treatment plan?
Yes. Goals/objectives can be generated from intake content and carried forward to the treatment plan.