31. How to Use Berries AI Progress Notes

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How to Use Berries AI Progress Notes

Are you ready to simplify your therapy documentation? Of course you are! In this episode, I’m diving into the Berries AI Progress Notes and showing you how you can use my very own progress note—yes, the one that passed an audit and is now integrated into Berries. If you’ve been stressed about documentation or worried about keeping your notes audit-proof, this tool is going to be a game-changer for you and I don’t say that lightly!

I’ll walk you through everything step-by-step, from how the note is structured to the AI features that make writing notes faster, easier, and more personalized. Plus, I’ll share tips on how you can start using Berries AI Progress Notes today to simplify your practice and save time.

AI Tips You Don’t Want to Miss:

  • See how Berries AI Progress Notes simplify compliance and documentation.
  • Get a step-by-step walkthrough of how to use Berries AI Progress Notes in your practice.
  • Discover how therapists are using this tool to streamline their workflows and reduce documentation stress.
  • Hear my personal tips for customizing the progress note to fit your unique style.
How to Use Berries AI Progress Notes

Mentioned in the Episode:

Connect with me:

Sponsored by Alma: www.helloalma.com/kym
Sponsored by Berries: www.berries.icu/therapists

Transcript: 

I’ve got a huge announcement I want to tell you guys about.

So you guys know I’m the clinical consultant for Berries. I help them develop the AI program, the note writing, the treatment planning, all that for therapists. So, a couple, maybe a month ago, I was talking to Tal and Yuval. They are the co founders of Berries. And they were like, we’ve got an idea. They’re like, you have a progress note, right?

That that has passed an audit that you think is a really good progress note, right? And I’m like, yeah, it’s my progress note. I share it with the people in my memberships in the A. I. Club and Bill like a boss. They have access to my note. It has passed an audit, thankfully you know, which makes us all really nervous.

I know to, to worry about audits and if it’s going to pass, I’ve perfected it over the years. I’ve edited. I’ve added things based on different.

And I’ve just continued to edit it over the years. Anyway, they were like, we have an idea. What if we put your audit proof note inside of Berries and gave access to anybody that wanted to activate your note within Berries and then use the magic of Berries AI to write the perfect progress note. I was like, yeah, let’s do it.

So it’s, it’s there. It’s live my progress note. It’s kind of wild cause I never even thought like, you know, I’d be able to access, give access to my progress note to like just anybody that wanted to have access to it publicly like this. So it’s really exciting for me to be able to share it with you guys.

So what you do, if you’re a berries user, you go to berries. icu slash therapists. Log in and go under my formats. And when you do that, you’ll see a box that is basically like a plus sign where you can add a new like personalized format inside of Barry’s. You click that you go over and there’s a little dialogue box box that’s gonna pop up.

And I’ll put a video under here for you guys to see exactly how to do it. But there’s a little box that pops up and if you start typing in KYM. T O L S O N, two words, Kim Tolson. And as you type it, it’s going to activate my personalized note format. You’re going to see confetti come on the screen, and it’s basically going to say your, your customized note has been unlocked, basically.

So it’s going to get unlocked, and then it’s going to be accessible to you inside of the Berries platform. Just so excited to share this with you guys. So if you’re using Berries, go try it out, activate it, you’re going to have access to that note. what’s going to happen is basically now every time you have a session in berries, you probably notice there’s a little drop down menu.

You click it and it’s like different note formats that you can basically apply to the note that you just did. They’ve got their standard default berries note, which is a great note to begin with. And you’ll notice that they’ve got some notes that you can use to add to your notes. They’ve got some notes that you can use to add to your notes, which is great.

So we’re going to go ahead and If you click it, it’ll transform whatever note you just wrote. It’ll put it into my personalized format, Kim Tolson’s note format, that has passed an audit. I’d like to just do a little disclaimer and say, just because it passed an audit for me, doesn’t necessarily mean it’s going to pass an audit for you.

So please, obviously, use your own discretion. Run it by whoever, you know, you run your documentation by. You can actually, once you have the format in there, you can actually click on it and you can edit it. So, like, the note will come up based on, you know, a session that you already had. The note will come up and you can go in there and actually edit it you can add sections.

You can take sections away and then save it. Take that saved note format and just it’ll be there. You can name it whatever you want. You can call it my, like, souped up version of Kim’s audit proof note. You can call it anything you want But that’s then going to save in your note formats too. So you’ll have my note there, you’ll have your edited version of my note there if you wanted to do that.

And every time you see, a new client or have a client session, you can just click that format and it’ll automatically do the note that way. if you’ve got it selected when you see the client it’ll just automatically default to that so you can have that as your default setting my note your note whatever note you want but I just wanted to tell you guys that you have access to it, I’m so excited to share it with you um if you use it I want to hear how it goes and what you think about the note and you know let me know The reasons it meets medical necessity and, I’m just gonna go through and just sort of highlight what makes it meet medical necessity I think that’s important for people to know 

 Barry’s has changed this for everybody. It basically is putting the date of the session and the actual time of the session, right? So for billing. , you need to have the time that you actually saw the client. So 10 0 4 to 10 54. Right? So that would make it 50 minutes.

That is not even long enough for a 9 0 8, 3 7, so you know it’s gotta be 53 minutes plus. So it’s got that, and then it actually even says the time next to it, 50 minutes for that session that this particular client, I’m looking at their note in the back end right now. . I only see her for 9 0 8, 3 4, so, so that’s why.

That’s okay. But, but basically it’s got that new feature. And then in my note, it says whether it was a telehealth or a face-to-face session, very important with your billing, because when you bill for telehealth, you have to put a two, a 10, or an 11 for location code. And that indicates whether it was telehealth or if it was in person.

So, the insurance companies want your note to basically reflect that and it, they want it to match your billing. So now this note. automatically does that for you. It also has location of the client at the time of the session. So home versus in office. So this note defaults to home for me because I’m always telehealth.

So the client is always sitting at their home at the time of the session. You do want to document that and some insurance companies even want you to go a step further and actually put the address of where the client was located at the time of the session. We don’t have that in here, but you can easily edit it when you copy and paste it over to your EHR.

And then I’ve got session content discussed in the session. This is where I use quotes of the actual problem that the client is having. And Berries does that for you if you guys have used it. It just pulls a quote from the client while you’re recording the session. And then in my note it talks about active symptoms, impairments, need for continued treatment.

So it outlines any symptoms or active impairments that would help meet medical necessity. So the insurance company knows, okay, check, check, check, difficulty concentrating, difficulty planning, emotional overwhelm, anxiety, all of that’s checked here. And then in my note, I have a mini mental status exam, but it’s very in depth.

It shows that I’m assessing for a lot of different things. cognitive functioning. Are they oriented times four? Are they logical? Are they relevant? Are they confused? Is their judgment impaired? This is just for cognitive functioning. And the way we’ve got it set up at Barry’s now is it’s going to check yes or no for each of these because my Actual note has a lot of check boxes in it But this basically is doing the check box for you.

It’s saying no, no, no. Yes. Yes. Yes And when you look at it, you’ll be able to see everything that I’m talking about But it even gets into self harm assessments, which a lot of notes don’t but it talks about are they self harming? Are they participating in, in eating issues like active harm, like by not eating or binging and purging, that sort of thing.

Self harm. Are they actively cutting, not cutting. Suicidal ideation, passive or with plan. All that’s in this note now. And then the overall assessment is the next part that’s super important in this note, and I added a lot to this that I know meets medical necessity. So it talks about the treatment Are they meeting their goals?

Are they not meeting their goals? And then what’s the treatment plan summary? And are we continuing with the current treatment plan or are we updating the treatment plan? And in Barry’s now, you know that if you click the treatment plan button, it writes a treatment plan for you. So if your note reflects like, Oh, we’ve gone astray from the treatment plan goals, you can now click in Barry’s and it’s just going to write you a new treatment plan based on what this note talked about, which is just blows my mind.

It’s so amazing. And then talks about the plan, what’s the plan, what’s the homework, what are we doing next week, homework goals and then recommendations and the, this is a medical necessity thing. The insurance companies want to know what is the plan for this client? Are we going to continue with this current therapeutic focus and frequency?

Yes. That’s a checkbox basically in this note now. Frequency, maintain bi weekly sessions, is how this note wrote, because I see her every other week. And I talked about it in a session, like, hey, when do you want to come back? Do you want to come in two weeks? Barry’s picks up on that, and already writes it into your notes, so the insurance company knows what your frequency’s going to be with this client.

Super important to them, they look for that in audits. Referrals, so this is where it would talk about like, you know, did we, Refer to a doctor, anything like that, that’s in here. The next section in this part is medical necessity factors influencing length or frequency of sessions. This is specifically, if you do a lot of 90837s, the insurance companies don’t want us to do a lot of 90837s.

So, this justifies it. Rapport, building rapport with the client. Additional session time requested by the client. History of trauma, yes. Client is in crisis, yes or no. Time needed to address and contain intense emotions, yes, prevent escalation to a more intensive level of care, yes. So all of these, and there’s many of them listed under the medical necessity, are justifications for billing a 90837, which a lot of notes are missing.

So I’ve got that in this note too for you. And then the very last thing that you don’t see in a lot of notes is estimated discharge timeline. Timeline, super important. This note defaults for three to six months, basically is what it defaults to. insurance companies always want you documenting that you’re working towards discharge with this client.

They want us to always be working towards getting them out the door, basically. So they want to know what is your estimated timeline that you’re going to see this client for? And are you even assessing that? This note covers that and makes sure that you’re assessing it and that you’re documenting it. So it defaults to three to six months, which is a pretty safe bet, but it’s still, you know, meeting that medical necessity piece.

So all of this is in that note that’s inside of Berries and, you know, if you’re not using Berries, hopefully that helps you too with your note a little bit. 

If you go to my format, you can activate my personalized note by typing in Kim Tolson, so K-Y-M-T-O-L-S-O-N. You know, two words, Kim Tolson. It’s gonna give you confetti and you know, activate that note inside of Barry. So I’m really excited to share that with you guys. I hope you’ll go try it and let me know what you think.

And down below this video, of course, I’ll put the discount code for Berries. It’s 50 from Kim. Gives you 50 off the first month of using Berries. It’s so worth it. It saves so much time and effort in the long run. I don’t know how much your time’s worth, but it, it is well worth it to me to be able to use a program like Berries that’s just evolving so quickly with so many new features.

Like, we’ve Just, Barry’s just started really a couple months ago. Now there’s treatment plans. Now there’s like these really optimized, like super optimized progress notes that you can use and the ability to do your in formats is really cool too. So super excited. Alright, I’ll see you guys next week