Search

Measurement-Informed Care and Documentation

This article provides an overview of how Measurement-Informed Care (MIC) is integrated into clinical documentation for the initial assessment and progress notes and how to utilize MIC data in sessions with clients.

MIC in the Initial Assessment

The Initial Assessment serves as the foundation for identifying treatment needs, establishing a diagnosis, and determining therapeutic fit. As such, information from the measurement surveys is an invaluable piece of information to have. 

If the client has completed the measurement surveys (e.g., GAD-7, PHQ-9, etc.) this will be integrated into the “Measures” section of the Initial Assessment note. Scores are color-coded and plotted on a severity scale which will help you quickly spot trends and notable shifts in self-reported behavior.

Here you see an example of the measurement survey results in the Initial Assessment note:

Initial assessment note with MIC_v2.png

MIC in Progress Notes

At Rula, you have the opportunity to choose from a Progress Note template or a SOAP note template to document treatment. Regardless of which template you select, completed measurement surveys will be integrated into the note and can be seen in the “Measures” section of the note.

Several past surveys are visible as well for comparison (the baseline survey and—if applicable—the most recent previous survey). This means up to three surveys may be present (Baseline, Previous session, This session). Scores are color-coded and plotted on a severity scale which will help you quickly spot trends and notable shifts in self-reported behavior.

Here you see an example of the measurement survey results in a Progress Note:

Progress note with MIC_v2.png

Utilizing MIC in Session with Clients

When completing documentation for an Initial Assessment or Progress Note, you'll be prompted to confirm whether you reviewed the client’s measures for the session. You’ll also need to select an action from a dropdown menu. 

Here you see where you would indicate whether you reviewed the measures and the dropdown menu of actions:

Review Measures.png

If a client has not completed the measures for this session or the previous session, you'll not be asked to select whether you reviewed the measures with your client. Instead, you'll see a message that reads, "A measurement has not been filled out by this client recently."

 

For more information on utilizing MIC with clients, check out these help center articles:

Was this article helpful?

1 out of 1 found this helpful