Clinijot — Smart Clinical Documentation

✦ Smart Clinical Documentation

What are you documenting today?

Select a category to get started

🧠 Therapy Notes

⚖️ Forensic Notes

🏥 Medical / Psychiatric Notes

🩺 Nursing / Allied Health

Nursing Care Plan Beta

Date

Discipline

Setting

📋 Patient Information

Patient Identifier / Case ID

Age / Gender

Medical / Psychiatric Diagnosis

🔍 Assessment

Nursing Assessment / Subjective & Objective Data

🎯 Nursing Diagnosis & Care Plan

Nursing Diagnosis (NANDA)

Goals / Expected Outcomes

Nursing Interventions

Evaluation / Patient Response

Writing your care plan

Clinical Case Study — RN / LVN Beta

Date

Discipline

Setting

Patient Demographics (de-identified)

Medical / Psychiatric Diagnosis

History & Presenting Problem

Assessment Findings

Nursing Diagnoses & Interventions

Outcomes & Evaluation

Clinical Reasoning / Reflection

Writing your case study

Suicide Risk Assessment Beta

Date

Provider

Setting

⚠️ Suicidal Ideation

Current SI

Denied SI Passive ideation Active SI without plan Active SI with plan SI with intent SI with means access Refused to answer

📋 Risk Factors

Historical Risk Factors

Prior suicide attempt(s) History of self-harm Family history of suicide Previous psychiatric hospitalization Trauma / abuse history Chronic mental illness Substance use history

Current Risk Factors

Hopelessness Recent significant loss Social isolation Access to lethal means Current substance use Recent psychiatric hospitalization Non-compliance with treatment Impulsivity Agitation / severe anxiety Command hallucinations

🛡️ Protective Factors

Reasons for living identified Strong social support Children / family responsibility Religious / spiritual beliefs Fear of death / pain Future-oriented thinking Engaged in treatment Safety plan in place

📊 Risk Level & Plan

Estimated Risk Level

Low risk Moderate risk High risk Imminent risk

Safety Plan / Interventions

Writing your assessment

Mental Health Juvenile Initial Evaluation Beta

Date

Provider

👤 Demographics

Age / Sex / Pronouns

Facility / Setting

👨‍👩‍👦 Family History

Living Situation Prior to Arrest / Guardian

Family MH / Substance History

Trauma / Abuse History

📚 Education & Development

Education

Developmental History

🏥 Psychiatric & Substance History

Psychiatric History

Substance Use History

⚠️ Risk Assessment

Risk Factors

Active SI Prior suicide attempt Prior suicide watch Non-adherent to medications First incarceration Hopelessness Impulsive Lacks social support Trauma history Substance intoxication / withdrawal

Protective Factors

Future goals identified Social support present Engaged in treatment Safety plan in place Family involvement

Estimated Risk Level

Low Intermediate High

🧠 Mental Status Exam

Appropriate appearance Disheveled Cooperative Guarded Euthymic mood Depressed Anxious Goal-directed thought Oriented x4 Insight fair Judgment fair

Clinical Impressions

Follow-Up Plan

MH follow-up within 7 days Begin Collaborative Safety Plan Refer to Psychiatric Prescriber General Population housing Mental Health Housing Suicide Watch

Writing your evaluation

Select Modality

CBT Session Note

Date

CPT Code / Duration

Format

Presenting Symptoms / Main Issue

💡 Quick picks:

Interventions Used

💡 Quick picks:

Client Response

💡 Quick picks:

Plan for Next Session

💡 Quick picks:

Concise — short paragraph Merge & Summarize — medium length Merge — full detailed note

Writing your clinical note

🔬 Medical Notes — Beta — This feature is in beta. Your feedback helps us improve SBAR and SOAPE templates for physicians, NPs, PAs, and other providers. Please share what works and what needs improvement.

SBAR Note Beta

Date

Provider Type

Setting

S — Situation: What is happening right now?

💡 Quick picks:

B — Background: Relevant history and context

💡 Quick picks:

A — Assessment: Your clinical judgment

💡 Quick picks:

R — Recommendation: What action is needed?

💡 Quick picks:

Writing your SBAR note

Mental Status Examination Beta

Date

Provider Type

Setting

Appearance & Behavior

Well-groomed Disheveled Casually dressed Age-appropriate appearance Poor hygiene Cooperative Guarded Hostile Eye contact maintained Avoided eye contact Psychomotor agitation Psychomotor retardation

Speech

Normal rate and tone Pressured Slow Soft Loud Disorganized Tangential Spontaneous Minimal verbal output

Mood & Affect

Mood (self-reported):

Euthymic Depressed Anxious Irritable Elevated Angry Neutral

Affect (observed):

Full range Restricted Flat Blunted Labile Congruent with mood Incongruent with mood Bright

Thought Process & Content

Process:

Goal-directed Logical Tangential Circumstantial Flight of ideas Loose associations Concrete Perseverative

Content:

No abnormal thought content Delusions present Paranoid ideation Ideas of reference Grandiosity Obsessive thoughts Somatic preoccupations

Perceptual Disturbances

No hallucinations reported Auditory hallucinations Visual hallucinations Command hallucinations Tactile hallucinations Denies AVH Derealization Depersonalization

Orientation & Cognition

Orientation:

Oriented x4 (person, place, time, situation) Oriented x3 Oriented x2 Disoriented

Attention / Concentration:

Intact Mildly impaired Moderately impaired Severely impaired Easily distracted

Memory:

Intact immediate recall Intact recent memory Intact remote memory Impaired recent memory Impaired remote memory

Insight & Judgment

Insight:

Good insight Fair insight Poor insight Absent insight Partial insight

Judgment:

Good judgment Fair judgment Poor judgment Impaired judgment

Suicidal / Homicidal Ideation

Suicidal Ideation:

Denied SI Passive SI Active SI without plan Active SI with plan SI with intent History of SI, denied current

Homicidal Ideation:

Denied HI Passive HI Active HI without plan Active HI with plan

Writing your MSE

Discharge / Transfer Note Beta

Date

Note Type

Provider Type

📋 Clinical Summary

Clinical Summary

Treatment Approach

Diagnoses at Discharge / Transfer

Patient Decision / Reason for Discharge

Mental Status at Discharge

Orientation & Appearance:

Alert and oriented x4 Alert and oriented x3 Well-groomed Cooperative Calm

Mood & Affect:

Mood improved Euthymic Affect appropriate Affect congruent Mood stable Residual anxiety Residual depression

Cognition & Insight:

Thought process logical Insight good Insight fair Judgment good Judgment fair

SI / HI:

Denied SI at discharge Denied HI at discharge No safety concerns at discharge

Medications at Discharge

📍 Disposition & Follow-Up

Discharge / Transfer Destination

Follow-Up Appointments

Safety Plan / Crisis Resources

Recommendations / Additional Notes

Writing your note