October offer: 50% off your first 3 months of Premium with code OCTOBER50 at checkout: USD $49.50/month, then USD $99/month. First-time customers only. Ends 31 October.Upgrade to Premium

Clinical Documentation Glossary

Search and Filter Terms

Filter by Category:
Affect Anhedonia Avolition Baseline Assessment Behavioral Activation Biopsychosocial Blunted Affect Chief Complaint Circumstantial Speech Clinical Formulation Clinical Impression Cognition Cognitive Restructuring Comorbidity Congruent Affect Constricted Affect Dialectical Behavior Therapy Differential Diagnosis Discharge Summary Dissociation EMDR Euthymic Exposure Therapy Flat Affect Flight Of Ideas Functional Impairment Hypervigilance Insight Judgment Labile Medical Necessity Mental Status Exam Mindfulness Based Intervention Mood Motivational Interviewing Orientation Outcome Measures Perception Presenting Problem Prognosis Progress Notes Psychoeducation Psychomotor Psychotherapy Notes Risk Assessment Screening Tools Severity Rating Tangential Speech Therapeutic Alliance Thought Content Thought Process Treatment Goals Treatment Plan

Write Better Notes Faster with AI Assistance

Use this glossary to understand clinical terminology, then let Mental Note AI help you incorporate these terms correctly into properly formatted clinical notes.

Try it free

Prefer Microsoft Word? Get the free Word add-in. Installs from Microsoft AppSource.

No credit card required. Works directly in Microsoft Word. You review and edit every draft.

Further Reading

  • APA Documentation Guidelines — Offers detailed guidelines on clinical documentation practices specific to psychology and mental health professionals.
  • DSM-5-TR — Provides standardized diagnostic criteria essential for clinical documentation in mental health.
  • HHS HIPAA — Covers legal requirements for protecting patient information within clinical documentation.

Write Better Notes, Faster

AI clinical notes in your browser or in Microsoft Word. HIPAA-compliant, with a BAA included on every plan. Free plan: 5 web-app scribe sessions a month, no credit card.

Try it free

Prefer Microsoft Word? Get the free Word add-in. Installs from Microsoft AppSource.