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Medical Record Notes

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Medical Record Notes

Almost all forms in PSYBooks have a section where you can enter notes. Most of these notes automatically become part of the client’s medical record, although a few allow you to designate the note as a personal psychotherapy note (i.e., not part of the medical record). PSYBooks breaks medical record notes into two categories: clinical medical record notes and admin medical record notes. This is done to allow you to give permission for a User to see one type of note but not others. For example, you might want your front office staff to be able to see your admin medical record notes (e.g., a note you might have attached to a client payment), but not your clinical medical record notes or your personal psychotherapy notes.

Most of the note types are assigned by PSYBooks, with notes that are more likely to contain sensitive information being in the clinical category, whereas notes that might be more administrative in nature (i.e., those pertaining to payments, claims, etc.) being categorized as admin notes. The various note types in PSYBooks are as follows:

Always in the Medical Record > Clinical category

  • Add/Edit Intake Form
  • Add/Edit Mental Status Exam (MSE)
  • Add/Edit Progress Note
  • Add/Edit Treatment Plan

Always in the Medical Record > Admin category

  • Add/Edit Adjustment
  • Add/Edit Authorization
  • Add/Edit Client Payment
  • Add/Edit Client Payment Allocation
  • Add/Edit ERA
  • Add/Edit Client Insurance
  • Add/Edit Insurance Payment Allocation
  • Add/Edit Resubmit Claim Note

Can be in Medical Record > Clinical or Psychotherapy categories (choice made by user):

  • Add/Edit Client
  • Add/Edit Session
  • Add/Edit Client Family
  • Add/Edit Client Medication

Always in the Psychotherapy (Personal) category

  • Add/Edit Open-Ended
2019-04-10T12:28:15-04:00

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Date of Last Revision: April 20, 2024

Welcome to our website (“Website”). These General Terms of Service (“Terms”) apply to visitors to this website, as well as registered users of any and all offerings provided by PSYBooks™. PSYBooks, LLC (“PSYBooks” or “we” or “our” or “us”) is a Georgia Limited Liability Company whose principal place of business is located at 2944 Blackwood Rd, Decatur, GA 30033.

PSYBooks is the owner and operator of this Website. PSYBooks, via our Website, provides an electronic health record (“EHR”) software-as-a-service (“Service”) offering specifically designed for mental health practices and may, in the future, offer other tools for those in the mental health professions.

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      DMCA Notification: PSYBooks, LLC

      Designated Agent: Susan Litton

      2944 Blackwood Rd

      Decatur, GA 30033

      Email: susan@psybooks.com

      Phone: 770-441-6361

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    3. In any arbitration involving this Agreement, the arbitrators shall not make any award that will alter, change, cancel or rescind any provision in this Agreement, and their award shall be consistent with the provisions of this Agreement. Any such arbitration must be commenced no later than one (1) year from the date such claim or controversy arose, or the claim is waived.
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  11. Severability
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  13. Definitions and Constructions
    1. Unless otherwise specified, the terms “includes,” “including,” “e.g.,”, “for example, and other similar terms are deemed to include the term “without limitation” immediately thereafter.

General Terms for Subscribers

The following Terms are for Subscribers to our Services. These Terms are in addition to the Terms in the Subscriber Agreement which must be accepted when you register.

  1. Acceptance and Modifications
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    1. Either you or PSYBooks may terminate this Agreement. You may terminate this Agreement by destroying all materials obtained from our Service, except for UGC and, if you are a Subscriber, by providing a termination notice to PSYBooks at support@psybooks.com. PSYBooks may terminate this Agreement immediately, without notice for any reason, or no reason, other than as provided for in our Subscriber Agreement, and reserves the right to block or prevent your future access to our Service.
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    3. You acknowledge and agree that termination of this Agreement by either party pertains solely to your use of our Service, and has no effect on other contractual obligations that may exist between the parties, which remain in full force and effect.

Privacy Policy

Date of Last Revision: April 20, 2024
  1. Introduction
    1. PSYBooks, LLC (collectively “PSYBooks” or “us” or “our” or “we”) is the owner and operator of www.psybooks.com and any related sub-domains (the “Service”). This privacy policy (“Privacy Policy” or “Policy”) applies to the Service in its entirety but does not apply to entities that PSYBooks does not own or control.
    2. PSYBooks is committed to the privacy and protection of information provided to us by our users. This includes any information provided to us through our Service, including any information submitted to us through various forms and through other mechanisms. By using our Service you are accepting the privacy practices contained in this Policy.
    3. The purpose of our Privacy Policy is to inform our users regarding the information that we collect, utilize, and share. If you have any questions about our Privacy Policy, or our privacy practices in general, please contact us using the contact information provided below:

    PSYBooks, LLC

    Privacy, c/o PSYBooks Privacy Officer

    2944 Blackwood Rd

    Decatur, GA 30033

    Email: susan@psybooks.com

    Phone: 770-441-6361

  2. Information Collected About You
    1. There are various types of information that PSYBooks collects about you when you register with, interact with, or otherwise use our Service. Some of this information is provided voluntarily by you and other information is provided through automated processes under PSYBooks’ control.
    2. Information Provided By You: In addition to personally identifiable information (“PII”) provided during the PSYBooks subscription process, you may also provide us PII during the following non-exhaustive list of representative classes of interactions on our Service:
      1. requesting customer support and sending PSYBooks similar communications;
      2. making payments to PSYBooks for various offerings;
      3. signing up for PSYBooks email alerts, newsletters, and similar special offers;
      4. responding to PSYBooks surveys and other special information requests; and
      5. communicating with PSYBooks regarding our compliance with applicable law.
    3. Information Provided By Automated Processes: PSYBooks may automatically collect non-PII pertaining to you when you use our Service including, but not limited to, when you use our Service via mobile and other access devices. PSYBooks may use cookies, web beacons, log files and similar methods to collect non-PII:
      1. A cookie is data stored in a small text file on your local access device that contains data about you. The information in the cookie is used to uniquely identify you and other users of our Service. The cookie may contain a token linked to our databases in order to provide you an enhanced feature set. It identifies a particular user at a particular point in time;
      2. A web beacon is used to enable communications with third parties. It is a small image in an HTML page with all dimensions set to one (1) pixel. Because of its insignificant size, it is not visible. It is used to pass certain non-PII anonymously to third-party sites, usually advertisers;
      3. A log file is a system created file that captures certain interactions between you and our Service.
    4. Non-PII Reservation of Rights: PSYBooks reserves the right to adopt alternative methods for collecting non-PII consistent with the provisions of this Policy and without providing further notification to you, other than what is contained herein.
  3. Implications Regarding Collected Information
    1. Consent Regarding Data Storage and Transfer: Your use of our Service implies your consent to have your PII and non-PII (“Data”) (i.e. any data provided by you to PSYBooks via our Service or through other mechanisms) stored, transferred and processed within the United States, or in any other country in which PSYBooks or its affiliates, subsidiaries or agents maintain facilities. By providing us with your Data and using our Service you consent to any such transfer of Data outside of your country of origin, at PSYBooks’ sole discretion.
    2. Control and Access to Data: PSYBooks respects both the need for you to control your Data and our users’ need for sharing it with us, especially regarding the protected health information (“PHI”) of patients. PSYBooks is diligent in ensuring that it has implemented appropriate administrative, technical, and physical safeguards to prevent the unauthorized or unlawful use of your Data, and to prevent any accidental loss, destruction, or damage to such information.
    3. Use of Data Collected: PSYBooks is the sole business owner of the Data (i.e. as represented by the aggregate content and arrangement of the information collected about you or your patients on our Service) and will not sell, rent or share the information collected in a manner that differs from what is disclosed in this Policy. PSYBooks collects this information in order to:
      1. accomplish the objectives of our Service;
      2. provide you with a high quality user experience on our Service;
      3. offer you a personalized feature set on our Service; and
      4. to improve our Service.
    4. Sharing of Data in General: PII or PHI provided by you will not be shared with third parties, without your permission, for any purpose other than those enumerated below. PSYBooks, in its sole discretion, reserves the right to share with third parties aggregated non-PII for the purpose of compiling information that is relevant to our business interests. PSYBooks, in its sole discretion, reserves the right to disclose any information that it obtains through our Service to appropriate governmental or regulatory authorities or governmental agencies, if required by law. PSYBooks, in its sole discretion, may share any information collected, stored and processed, if it has a good faith belief that to do so is reasonably necessary to:
      1. enforce our Terms of Use;
      2. detect, investigate and otherwise address fraud, security or technical breaches or related matters; or
      3. protect against imminent harm to the rights, property, or safety of PSYBooks, its users, or the public at large, as required or permitted by law.
    5. Sharing of Payment Data: PSYBooks may share transaction information with our third party payment processor (“Payment Processor”) when you pay for or renew your Subscription to our Service. The information shared with our Payment Processor is limited to the information required by our Payment Processor to complete the payment transaction. PSYBooks does not capture or store the financial information provided by you to our Payment Processor. PSYBooks only stores the results of said transactions as provided via notifications from our Payment Processor to us upon the completion of a payment transaction.
    6. Sharing of Data with Other Third Parties: In addition to disclosing information to our Payment Processor, PSYBooks may disclose your personal information or PHI to other third-party service providers (“Providers”) who perform services on our behalf. Examples of such Providers may include, but are not limited to, data storage and web hosting companies, as well as consultants we may engage for various reasons. PSYBooks requires Providers to use and protect your personal information consistent with the provisions of this Policy. PHI will only be shared with business partners with whom PSYBooks has a Business Associate Agreement, as required by applicable law.
  4. Security of Information
    1. Any information sent by you to PSYBooks through Internet email or through our Service may not be secure and is therefore done on a non-confidential basis and at your own risk. Once such information is received, PSYBooks takes appropriate security safeguards to prevent its unauthorized use, alteration, disclosure or destruction. These safeguards include periodic review of our internal processes, and benchmarking of same with industry best practices.
    2. Access to PII or PHI is restricted to PSYBooks employees, contractors, and agents on a need to know basis. Such individuals are generally bound by confidentiality agreements and may be subject to termination and criminal prosecution should they fail to comply as required by said agreements and/or with the contents of this Policy.
  5. Data integrity
    1. PSYBooks processes PII only for the purposes for which it was collected and in accordance with the provisions in this Policy. Reasonable steps are taken to ensure the quality of the PII that PSYBooks collects, processes, and stores. PSYBooks depends on its users to keep their PII current and accurate. PSYBooks conducts periodic reviews to ensure that only the PII required by our Service is captured and used consistent with the provisions of this Policy. The maintenance of data integrity is a joint collaborative effort between PSYBooks and our users.
    2. PSYBooks may delete Data, from time to time, upon the request of an individual user. PSYBooks requires that a user present proper credentials for authentication before honoring all such requests. Good faith attempts are made to work with individual users regarding Data related issues. PSYBooks reserves the right to refuse such requests when they prove unduly burdensome and/or are impractical. PSYBooks will not delete Data required to be kept by applicable law or Data otherwise required by PSYBooks for legitimate business reasons.
  6. Choices Regarding PII
    1. Should PSYBooks decide to use PII or PHI other than for the purpose originally collected, PSYBooks will do so only with your consent. You will be given the opportunity to opt out of any such use. Should PSYBooks become involved in a sale, acquisition, or any form of transfer of some or all of its assets, then PSYBooks will provide notice to you before your PII or PHI is subject to a new or different privacy policy.
    2. You always have the option of contacting PSYBooks should you have questions regarding your PII or PHI. Please contact PSYBooks using the contact information provided above.
  7. Protecting Children

    PSYBooks restricts the use of our Service to individuals of legal age and above. PSYBooks does not knowingly collect or solicit PII from anyone under the age of 18, with or without parental consent.

  8. Links

    Our Service may contain hyperlinks to third-party websites that may collect or solicit information. Our Privacy Policy does not cover information collected or solicited by these third-party websites. PSYBooks is not responsible for the privacy practices of such sites. PSYBooks users are encouraged to pay attention when they leave our Service and to read the respective privacy policies of each website that collects personally identifiable information. This Policy only applies to information provided by you to PSYBooks via our Service or through other mechanisms.

  9. Enforcement

    Because we are committed to protecting our users’ PII and PHI, PSYBooks conducts periodic reviews of our internal processes to ensure that we remain in compliance with this Policy. We will cooperate with the appropriate authorities to resolve any user complaints regarding the transfer of PII or PHI. PSYBooks will initially try to resolve the complaint with the individual user. Formal complaints should be sent to PSYBooks using the contact information provided above.

  10. Policy Changes

    In the future, we may make changes to our Privacy Policy to reflect changes in our privacy practices and/or changes to our Service. PSYBooks’ goal is to keep our users aware of what information we collect, use, and under what circumstances, if any, we disclose it. When changes are made to this Policy the “last updated date” will be modified accordingly. If changes are made to our Privacy Policy then PSYBooks will provide notification on our Website. In addition, further notification will be provided to users that have registered with our Service.

Business Agreement

Date of Last Revision: April 20, 2024
  1. Introduction
    1. PSYBooks, LLC (collectively “PSYBooks” or “us” or “our” or “we”) is the owner and operator of www.psybooks.com and any related sub-domains (the “Service”). This privacy policy (“Privacy Policy” or “Policy”) applies to the Service in its entirety but does not apply to entities that PSYBooks does not own or control.
    2. PSYBooks is committed to the privacy and protection of information provided to us by our users. This includes any information provided to us through our Service, including any information submitted to us through various forms and through other mechanisms. By using our Service you are accepting the privacy practices contained in this Policy.
    3. The purpose of our Privacy Policy is to inform our users regarding the information that we collect, utilize, and share. If you have any questions about our Privacy Policy, or our privacy practices in general, please contact us using the contact information provided below:

    PSYBooks, LLC

    Privacy, c/o PSYBooks Privacy Officer

    2944 Blackwood Rd

    Decatur, GA 30033

    Email: susan@psybooks.com

    Phone: 770-441-6361

  2. Information Collected About You
    1. There are various types of information that PSYBooks collects about you when you register with, interact with, or otherwise use our Service. Some of this information is provided voluntarily by you and other information is provided through automated processes under PSYBooks’ control.
    2. Information Provided By You: In addition to personally identifiable information (“PII”) provided during the PSYBooks subscription process, you may also provide us PII during the following non-exhaustive list of representative classes of interactions on our Service:
      1. requesting customer support and sending PSYBooks similar communications;
      2. making payments to PSYBooks for various offerings;
      3. signing up for PSYBooks email alerts, newsletters, and similar special offers;
      4. responding to PSYBooks surveys and other special information requests; and
      5. communicating with PSYBooks regarding our compliance with applicable law.
    3. Information Provided By Automated Processes: PSYBooks may automatically collect non-PII pertaining to you when you use our Service including, but not limited to, when you use our Service via mobile and other access devices. PSYBooks may use cookies, web beacons, log files and similar methods to collect non-PII:
      1. A cookie is data stored in a small text file on your local access device that contains data about you. The information in the cookie is used to uniquely identify you and other users of our Service. The cookie may contain a token linked to our databases in order to provide you an enhanced feature set. It identifies a particular user at a particular point in time;
      2. A web beacon is used to enable communications with third parties. It is a small image in an HTML page with all dimensions set to one (1) pixel. Because of its insignificant size, it is not visible. It is used to pass certain non-PII anonymously to third-party sites, usually advertisers;
      3. A log file is a system created file that captures certain interactions between you and our Service.
    4. Non-PII Reservation of Rights: PSYBooks reserves the right to adopt alternative methods for collecting non-PII consistent with the provisions of this Policy and without providing further notification to you, other than what is contained herein.
  3. Implications Regarding Collected Information
    1. Consent Regarding Data Storage and Transfer: Your use of our Service implies your consent to have your PII and non-PII (“Data”) (i.e. any data provided by you to PSYBooks via our Service or through other mechanisms) stored, transferred and processed within the United States, or in any other country in which PSYBooks or its affiliates, subsidiaries or agents maintain facilities. By providing us with your Data and using our Service you consent to any such transfer of Data outside of your country of origin, at PSYBooks’ sole discretion.
    2. Control and Access to Data: PSYBooks respects both the need for you to control your Data and our users’ need for sharing it with us, especially regarding the protected health information (“PHI”) of patients. PSYBooks is diligent in ensuring that it has implemented appropriate administrative, technical, and physical safeguards to prevent the unauthorized or unlawful use of your Data, and to prevent any accidental loss, destruction, or damage to such information.
    3. Use of Data Collected: PSYBooks is the sole business owner of the Data (i.e. as represented by the aggregate content and arrangement of the information collected about you or your patients on our Service) and will not sell, rent or share the information collected in a manner that differs from what is disclosed in this Policy. PSYBooks collects this information in order to:
      1. accomplish the objectives of our Service;
      2. provide you with a high quality user experience on our Service;
      3. offer you a personalized feature set on our Service; and
      4. to improve our Service.
    4. Sharing of Data in General: PII or PHI provided by you will not be shared with third parties, without your permission, for any purpose other than those enumerated below. PSYBooks, in its sole discretion, reserves the right to share with third parties aggregated non-PII for the purpose of compiling information that is relevant to our business interests. PSYBooks, in its sole discretion, reserves the right to disclose any information that it obtains through our Service to appropriate governmental or regulatory authorities or governmental agencies, if required by law. PSYBooks, in its sole discretion, may share any information collected, stored and processed, if it has a good faith belief that to do so is reasonably necessary to:
      1. enforce our Terms of Use;
      2. detect, investigate and otherwise address fraud, security or technical breaches or related matters; or
      3. protect against imminent harm to the rights, property, or safety of PSYBooks, its users, or the public at large, as required or permitted by law.
    5. Sharing of Payment Data: PSYBooks may share transaction information with our third party payment processor (“Payment Processor”) when you pay for or renew your Subscription to our Service. The information shared with our Payment Processor is limited to the information required by our Payment Processor to complete the payment transaction. PSYBooks does not capture or store the financial information provided by you to our Payment Processor. PSYBooks only stores the results of said transactions as provided via notifications from our Payment Processor to us upon the completion of a payment transaction.
    6. Sharing of Data with Other Third Parties: In addition to disclosing information to our Payment Processor, PSYBooks may disclose your personal information or PHI to other third-party service providers (“Providers”) who perform services on our behalf. Examples of such Providers may include, but are not limited to, data storage and web hosting companies, as well as consultants we may engage for various reasons. PSYBooks requires Providers to use and protect your personal information consistent with the provisions of this Policy. PHI will only be shared with business partners with whom PSYBooks has a Business Associate Agreement, as required by applicable law.
  4. Security of Information
    1. Any information sent by you to PSYBooks through Internet email or through our Service may not be secure and is therefore done on a non-confidential basis and at your own risk. Once such information is received, PSYBooks takes appropriate security safeguards to prevent its unauthorized use, alteration, disclosure or destruction. These safeguards include periodic review of our internal processes, and benchmarking of same with industry best practices.
    2. Access to PII or PHI is restricted to PSYBooks employees, contractors, and agents on a need to know basis. Such individuals are generally bound by confidentiality agreements and may be subject to termination and criminal prosecution should they fail to comply as required by said agreements and/or with the contents of this Policy.
  5. Data integrity
    1. PSYBooks processes PII only for the purposes for which it was collected and in accordance with the provisions in this Policy. Reasonable steps are taken to ensure the quality of the PII that PSYBooks collects, processes, and stores. PSYBooks depends on its users to keep their PII current and accurate. PSYBooks conducts periodic reviews to ensure that only the PII required by our Service is captured and used consistent with the provisions of this Policy. The maintenance of data integrity is a joint collaborative effort between PSYBooks and our users.
    2. PSYBooks may delete Data, from time to time, upon the request of an individual user. PSYBooks requires that a user present proper credentials for authentication before honoring all such requests. Good faith attempts are made to work with individual users regarding Data related issues. PSYBooks reserves the right to refuse such requests when they prove unduly burdensome and/or are impractical. PSYBooks will not delete Data required to be kept by applicable law or Data otherwise required by PSYBooks for legitimate business reasons.
  6. Choices Regarding PII
    1. Should PSYBooks decide to use PII or PHI other than for the purpose originally collected, PSYBooks will do so only with your consent. You will be given the opportunity to opt out of any such use. Should PSYBooks become involved in a sale, acquisition, or any form of transfer of some or all of its assets, then PSYBooks will provide notice to you before your PII or PHI is subject to a new or different privacy policy.
    2. You always have the option of contacting PSYBooks should you have questions regarding your PII or PHI. Please contact PSYBooks using the contact information provided above.
  7. Protecting Children

    PSYBooks restricts the use of our Service to individuals of legal age and above. PSYBooks does not knowingly collect or solicit PII from anyone under the age of 18, with or without parental consent.

  8. Links

    Our Service may contain hyperlinks to third-party websites that may collect or solicit information. Our Privacy Policy does not cover information collected or solicited by these third-party websites. PSYBooks is not responsible for the privacy practices of such sites. PSYBooks users are encouraged to pay attention when they leave our Service and to read the respective privacy policies of each website that collects personally identifiable information. This Policy only applies to information provided by you to PSYBooks via our Service or through other mechanisms.

  9. Enforcement

    Because we are committed to protecting our users’ PII and PHI, PSYBooks conducts periodic reviews of our internal processes to ensure that we remain in compliance with this Policy. We will cooperate with the appropriate authorities to resolve any user complaints regarding the transfer of PII or PHI. PSYBooks will initially try to resolve the complaint with the individual user. Formal complaints should be sent to PSYBooks using the contact information provided above.

  10. Policy Changes

    In the future, we may make changes to our Privacy Policy to reflect changes in our privacy practices and/or changes to our Service. PSYBooks’ goal is to keep our users aware of what information we collect, use, and under what circumstances, if any, we disclose it. When changes are made to this Policy the “last updated date” will be modified accordingly. If changes are made to our Privacy Policy then PSYBooks will provide notification on our Website. In addition, further notification will be provided to users that have registered with our Service.