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Keep your attention on the care encounter.
Record the conversation and clearly state your own findings and agreed actions.
Hysio Healthcare Psychology
Hysio organises your healthcare psychology intake, session, evaluation or assessment report into a source-bound text. You keep the professional formulation and the choice of what goes into the record.
A structured report in your professional terminology
From care encounter to report
Hysio turns spoken information into a report. Choose the report format for the conversation you are documenting.
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Record the conversation and clearly state your own findings and agreed actions.
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State relevant information, your own findings and agreed actions aloud so you can find them in your report.
The information appears under the headings of your chosen report format, so you can review each section.
Check names, facts and agreed actions. Edit the text where needed before using the report in your records.
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Quick answer
Four documentation formats for the healthcare psychologist: intake, treatment session, evaluation with handover and an assessment report. Your formulation and your choice for the record remain decisive.
Each format has fixed parts: registration and request for help, complaints, functioning and context, observations and professional formulation, and the agreements about next steps.
Hysio groups four profession-specific documentation formats for the healthcare psychologist: the Healthcare Psychology Intake for a first contact, the Healthcare Psychology Treatment Session for a single session, the Healthcare Psychology Evaluation & Handover for an evaluation or handover, and the Healthcare Psychology Assessment Report after psychodiagnostic assessment. Each assistant is intended for a specific purpose of the encounter. Client, referrer and healthcare psychologist remain recognisable sources, while you assess the professional formulation, the consent and the final choice of what goes in the record. [1] [2] [3] [4] [5] [6] [9]
Hysio Healthcare Psychology Intake puts the registration, the referral and the request for help in a section of their own, alongside complaints, functioning and context. Relevant history and source information get a separate section, as do observations, examination and your professional formulation. Goals, treatment direction and agreements close the report. The request for help stays in the client's own words; what the referrer supplied and what you observed yourself are kept apart from it. You review the formulation and decide what goes into the record. [1] [2] [5] [6]
The Healthcare Psychology Treatment Session fits when you record a single treatment session and not a first contact. The structure starts with the encounter context and session focus, and then keeps the client's perspective and current functioning together. Goals, interventions carried out and the response to them have a section of their own, separate from your observations and professional considerations. Measurement and risk information stays tied to the source. If it concerns an evaluation or a handover, the Evaluation & Handover is intended instead. [1] [3] [5] [6]
In the Healthcare Psychology Evaluation & Handover, your professional evaluation and decision have a section of their own, apart from goals, progress and the client's perspective. The explicit next steps return under continuity, agreements and open points. The handover section records who the recipient is and which consent was discussed for this. Only what was said in the evaluation conversation or in a linked care pathway source ends up in those sections. Hysio does not formulate an evaluation itself and does not make a decision. [1] [4] [5] [6]
The Healthcare Psychology Intake starts with registration, referral and request for help: how the client presents and what the question is at that moment. The Healthcare Psychology Evaluation & Handover starts with the evaluation framework and the treatment period, and looks back on goals, progress and the client's perspective. The request for help returns there as a reference point, not as a starting point. The intake closes with treatment direction and agreements; the evaluation closes with recipient, consent and continuity. [1] [2] [4] [5] [6]
Registration and the request for help get a section of their own in the intake report, before complaints, functioning and context. You note who referred and with what question, and the request for help stays as close as possible to the client's wording. If the referrer's question differs from the client's, both remain visible side by side. Hysio does not add a request for help that was not expressed. You sharpen the formulation and decide what goes into the record. [1] [2] [5] [6]
Yes, provided they were discussed in the encounter. Hysio records a questionnaire or measurement as it was named, with the instrument name, time of administration and source, and does not turn the outcome into a score, norm or advice. If the result is missing, that stays recorded as such. In the intake report, these data go under observations and examination, separate from your professional formulation. You assess the meaning and decide what is saved. [1] [2] [5] [6]
Your interpretation has a section of its own and never sits between the source sentences. In the intake report, that is the section with observations, examination and professional formulation; in the session report, it is the observations and professional considerations. What the client said about the request for help and what a referrer wrote stays outside it, in reported speech. Hysio does not move interpretation to the client section and does not turn an observation into a conclusion. That way, a reader sees which sentence comes from you. [1] [2] [3] [4] [5] [6]
Give each source a place and a label of its own. What the client tells you goes in the section on the client's perspective and functioning, in reported speech. What a referrer or an external letter supplies goes under source information, with date and sender. What you saw or weighed goes under your observations and professional considerations. If two sources contradict each other, both remain and you note the difference. Hysio does not pick a winning version; you weigh the meaning. [1] [2] [3] [4] [5] [6]
In the intake report, you record registration and request for help with the source they come from; in the evaluation and handover report, the same applies to goals, progress and measurement data. Hysio organises those parts and keeps their origin attached, while you check the client context, consent and the final choice of what goes in the record. That keeps visible what the client said, what a referrer supplied and what you observed yourself. [1] [2] [3] [4] [5] [6]
State out loud who referred, when the registration came in and what question the client brings. Use the client's wording for this and say separately how the referrer described the question. Mention what has been tried before and what is most pressing right now. Hysio places those sentences in the section on registration, referral and request for help and leaves empty what was not said. You sharpen the formulation before the report goes to the record. [1] [2] [5] [6]
The intake report contains the request for help as the client formulates it, together with the referral question and the reason for registration. It also includes complaints, functioning and context, plus relevant history and information from other sources. What you observed yourself and how you professionally formulate the picture has a section of its own, with goals, treatment direction and agreements at the end. What was not discussed stays open, instead of Hysio filling it in. [1] [2] [5] [6]
In the intake report, the client's perspective sits in the broader section on complaints, functioning and context: how the complaint arose, what is going on and what has been tried before. In the session report, the same topic concerns a single session: how the client now describes their functioning, against the session focus of that encounter. The intake builds up the picture; the treatment session records the change per encounter. Both keep your considerations separate from what the client said. [1] [2] [3] [5] [6]
This format is intended for looking back on a treatment period or handing over the care pathway, when your professional evaluation must be explicit in the report. The conversation and the linked care pathway sources then come together in one internal report, with goals, progress, measurement data and your evaluation and decision. For a single session, the Treatment Session fits better; for a first contact, the Intake. Hysio does not formulate the evaluation itself. [1] [4] [5] [6]
Record the course of symptoms with a timeline and a source per point: what the client says about the course, what is in an earlier letter and what you saw yourself. Add dates, even when they were given approximately. If the client's account diverges from an earlier report, both versions remain with their origin. Hysio does not turn that difference into a smooth summary; you weigh what the course means professionally. [1] [2] [3] [4] [5] [6]
While dictating, say out loud each time where the information comes from: the client told me this, this was in the referral letter, I saw this myself. Avoid sentences in which those three run together; that keeps voice-driven admin in mental healthcare traceable. Name doubt as doubt and an intention as an intention. Hysio keeps to the roles you state and does not invent any; what stays without a source does not enter the report as a finding. When reviewing, you check whether each sentence still sits with the right voice. [1] [2] [3] [4] [5] [6]
Let the follow-up agreement follow from what you have formulated. In the conversation, name which goal you are pursuing, which step is needed for it and when you will evaluate it. In the intake report, that goes under goals, treatment direction and agreements; in the session report, under agreements, next steps and open points. What has not yet been agreed remains an open point. Hysio does not link a goal to a next step that was not expressed, and you decide the final formulation. [1] [2] [3] [4] [5] [6]
First describe what was observable and only then what you infer from it. An observation is concrete: the client came in late, spoke quietly, broke off the conversation twice. An interpretation adds meaning and belongs in your professional considerations, with words that mark it as such, for example I weigh or my impression is. Hysio keeps both parts apart and does not turn an observation into a conclusion. When reviewing, you check whether each interpreted sentence can be traced back to an observation. [1] [2] [3] [4] [5] [6]
Leave it empty and make visible that it is empty. Hysio does not fill in a client's perspective that was not expressed and does not infer functioning from a complaint. If there is partial information, the usable part goes into the report together with what specifically is missing. Uncertainty from the source remains, so words such as presumably or possibly do not disappear. At the next encounter you ask specifically about what was missing, and you decide whether the report can go into the record as it is. [1] [2] [3] [4] [5] [6]
Take an intake in which the client describes stress-related complaints, mentions difficulty with work, refers to previous help and discusses a treatment plan with you. The stress-related complaints and functioning then go under complaints, functioning and context; the previous help under history and source information; the discussed plan under goals, treatment direction and agreements. The request for help stays above them as the reference point against which those sections can be read. Hysio does not link the parts into a conclusion; you formulate what the picture means. [1] [2] [3] [4] [5] [6]
On registration and the request for help, the record carries four things: who referred and when, with what question the client presents, how the referrer describes that question and which agreements about consent were made. Each point comes with its origin and date. If the request for help changes during the care pathway, the new formulation is added and does not replace the old one. Hysio adds nothing that is not in a source, and you decide what is saved. [1] [2] [3] [4] [6] [7]
Keep the client's perspective as close as possible to the client's own words and mark where you quote or summarise. Put your judgement in a separate paragraph with its own opening, so that a later reader does not have to guess who thinks what. Describe functioning with examples from the conversation instead of with a label. Hysio does not move any sentence from one section to another. If you notice a mix-up when reviewing, correct it before you save. [1] [2] [3] [4] [6] [7]
Each source gets a name, a date and a role. Besides the client and the referrer, a family member or someone close, a GP or a previous practitioner can also supply information; that information goes under collateral or source information and not in the client section. Note whether the client knows that this information was shared and whether consent for it was discussed. With voice-driven reporting, Hysio does not attribute a source that was not named. You check whether the attribution is correct before the report goes to the record. [1] [2] [3] [4] [6] [7]
Record what consent was given for, to whom, for what period and whether it is verbal or written consent. That applies both to requesting information from a referrer or someone close and to sharing an evaluation or handover. In the evaluation and handover report, recipient and consent have a section of their own. If no consent was discussed, Hysio does not write that the client agrees. You assess whether sharing is responsible at this moment. [1] [2] [3] [4] [6] [7]
Put both side by side instead of turning them into one story. The request for help is what the client asks for; the course of symptoms is how the complaints developed over time. If they differ, for example a request for help with sleep while the course is mainly about work pressure, you note both with their source and date. The difference itself is information, not an error in the report. Hysio does not smooth that difference away; you weigh what it means for the treatment direction. [1] [2] [3] [4] [6] [7]
What goes along is the evaluation framework and the treatment period, the goals with their progress and the client's perspective on them, the interventions carried out with response and measurement data, and the source-bound risk information. Then follow your professional evaluation and decision, the purpose of the handover with the recipient and the consent discussed, and finally continuity, agreements and open points. What is not in the conversation or in a linked care pathway source does not go along. You decide what the recipient ultimately receives. [1] [4] [6] [7]
A decision is explicit when it was stated in the encounter and not only thought: you name what you decide, on what grounds and what it means for next steps. Say it out loud, also when it concerns refraining from a step or postponing until a next encounter. What remains a consideration belongs in the professional considerations and not in the agreements. Hysio does not turn a consideration into a decision, and you guard that boundary before you save. [1] [2] [3] [4] [6] [7]
Especially sensitive are data about third parties, about previous treatments, about safety and about areas of life outside the request for help, such as work, faith, sexuality or contact with the justice system. Include only what is needed for this treatment, in the words used in the conversation. Describe a third party as sparingly as possible and traceable to the client who talked about them. Hysio does not weigh that proportionality itself; you decide what goes into the record and what you leave out. [1] [2] [3] [4] [6] [7]
For an external letter, note who wrote it, when, and what it literally says that matters for this encounter. Put that content under source information and not among your own observations. Clinimetrics get a line of their own with instrument name, version, date of administration and who administered it. If the letter contradicts a measurement, both remain with their date. Hysio does not copy a conclusion from a letter into your formulation; you make that judgement yourself. [1] [2] [3] [4] [6] [7]
The boundary lies at judgement. Hysio does not independently make a diagnosis, DSM classification or hypothesis, does not assess risk and does not make a treatment decision. Hysio only organises what a source recorded in the encounter; you check the text and decide what goes into the record. A classification or indication only goes in as an attributed statement. Make visible in the record which source contributed the information and which assessment you made yourself. [1] [2] [3] [4] [6] [7]
Hysio does not commit to a fixed list. What fits is what is customary in your practice and was discussed in the encounter: complaint-specific questionnaires, measures of general functioning and repeated measurements to follow progress. What matters is not which instrument you name, but that instrument name, version, date of administration, source, literal result and your interpretation stay separate. Hysio does not calculate, standardise or interpret anything itself. You decide which measurement has meaning for this care pathway. [1] [2] [3] [4] [6] [7] [8]
Describe behaviour and statements, not meaning. For example: the client says they have been waking earlier for three weeks and reported two sleepless nights today. Avoid words that already carry a judgement, such as deteriorated or relapse, unless the client uses them and you note that as a quote. Add date and source. What you make of that course belongs in your professional considerations. Hysio does not add a direction to an observation. [1] [2] [3] [4] [6] [7] [8]
Risk information and safety agreements have a section of their own, so they do not disappear among other observations. In the session report, that is the section with measurement and risk information; in the evaluation and handover report, the source-bound risk information. Keep the client's answer, your own observation, a named risk factor or protective factor and your risk judgement apart, with source and time. Silence is not a finding. Hysio does not add a risk level, reassurance or urgency. [1] [2] [3] [4] [6] [7] [8]
Include what was said in the encounter: which substance or medication came up, who said so and since when. Name, strength, dosage and frequency are only included as they were mentioned or provided. Keep reported use, effect, side effect and a professional decision separate. A healthcare psychologist does not prescribe anything, so this remains source information and not advice. Hysio never suggests medication, a dosage or a change. If the situation calls for consultation with the prescriber, record that as an agreement. [1] [2] [3] [4] [6] [7] [8]
If the clinimetrics were carried out but no result is available, note that the administration took place and state the date and source context. Leave the result empty or mark it as not documented; Hysio does not invent a score, interpretation or advice. The healthcare psychologist checks the text and decides what goes into the record. [1] [2] [3] [4] [6] [7] [8]
Let the contradiction stand and name it. Put both versions with their source and date in the report and mark that they differ, so the point can be verified. Ask further in the encounter if possible, and record the answer as a new source sentence rather than as a correction of the old one. Only a clear later correction replaces the item it corrects. Hysio does not choose which source is right and does not make a compromise; you weigh the meaning. [1] [2] [3] [4] [6] [7] [8]
Describe what you actually did in this session and keep it separate from what you proposed. Name the intervention as you carried it out, the goal it was linked to and how the client responded, in their own words or in observable behaviour. A proposal that has not yet been carried out belongs with the agreements and next steps; an announced test remains an intention. Hysio does not turn an intention into an action carried out. [1] [2] [3] [4] [6] [7] [8]
Put the goal, the measurement and the client's statement side by side and leave the conclusion to you. Note what has been done since last time and what was observed of it, with date. If comparison information is missing, progress stays descriptive and you do not write that there is improvement, standstill or relapse. State explicitly in your professional considerations what you infer and from what. Hysio does not calculate change and does not formulate a result that was not expressed. [1] [2] [3] [4] [6] [7] [8]
You need the language that keeps question, complaint and meaning apart: request for help and referral question, history-taking and collateral history, course of symptoms, functioning and context, professional formulation and treatment direction. Use those words as they apply in your own professional group and do not put meaning into them that the conversation did not carry. Avoid a classifying term when only a description was given. Hysio adopts the professional language you use and does not choose a heavier term itself. [1] [2] [3] [4] [6] [7] [8]
Check four things. Does the source match each sentence: client, referrer, another source or yourself? Are date and context given for measurements, letters and agreements? Is your interpretation recognisably separate from what was observed? And is there nothing in it that was not said, from request for help to safety agreement? Then you assess whether the professional language covers what is meant and whether the text belongs in this record. Voice-driven reporting delivers a proposal; you decide the final content. [1] [2] [3] [4] [6] [7] [8]
Start with the registration and formulate the request for help in the client's words. Also note the course of symptoms, context and any clinimetrics, each with their own source. Hysio places that information side by side. The healthcare psychologist reviews the proposal, adds professional interpretation and decides what belongs in the record. Keep the course of symptoms, the client's perspective and clinimetrics in the same source context, so that a later conversation can build on it. [1] [2] [3] [4] [5] [6]
Fixed sections mean you do not have to work out every time where something belongs. That keeps admin with AI clear. The request for help is always in the same place, so a colleague or you yourself can find it without reading the whole report. Because source, observation and interpretation each have a section of their own, what is missing stands out immediately. At a next encounter you build on the same layout and compare progress. Hysio fills the sections with what was said; you assess whether the picture is correct. [1] [2] [3] [4] [5] [6]
Always review the proposal yourself before anything is saved. Start with the client's account, put what the referrer supplied next to it, and only then formulate your own judgement. Hysio may bring both sources together, but does not make a diagnosis, DSM classification, risk assessment or treatment decision. Discuss uncertainties and leave them as uncertainty. A loose impression does not gain meaning without the question and the circumstances in which it arose. [1] [2] [3] [4] [5] [6]
No. Hysio does not take over any diagnostic or therapeutic decision and does not make a DSM classification, diagnosis, risk assessment or treatment decision. The platform can, however, organise source sentences and discussed next steps. The healthcare psychologist checks origin and context and then approves the professional formulation. A neat summary of the course of symptoms, the client's perspective and clinimetrics does not turn uncertainty into an established professional fact. [1] [2] [3] [4] [5] [6]
Note the questionnaire, the date of administration and the score as provided, for example an OQ-45 or SQ-48. What the client says about the outcome and your interpretation go separately. Hysio does not calculate scores or apply norms; you decide what the measurement means for the treatment. [1] [2] [3] [4] [5] [6]
Those boundaries do not come from Hysio. They are set out in the professional code that applies to your registration, in the statutory rules around the treatment agreement and in your own organisation's record-keeping arrangements. In the report you therefore only describe who contributed something, when that happened and which consent or limitation came up. Hysio does not turn that into a legal conclusion. When in doubt, you leave the point open until you have checked it yourself. [1] [2] [3] [4] [5] [6]
If no layout fits the encounter, note what is missing and follow your own reporting route. Keep an open point recognisable. Hysio does not invent intake data and does not choose another professional format. The healthcare psychologist assesses the source, records the reason for deviating and decides the final note. Briefly note which route you then follow in your practice. [1] [2] [3] [4] [5] [6]
After a busy conversation, first make a short core note on registration, request for help and next steps. Link each point to the client, the referrer or your own observation. Hysio can support the order. The healthcare psychologist checks date, context and formulation and removes assumptions before the record is updated. That way, a colleague can trace the origin of the course of symptoms, the client's perspective and clinimetrics, and the outstanding next steps. [1] [2] [3] [4] [5] [6]
Both record the same kind of encounter, but the professional role differs and with it what carries weight in the report. In healthcare psychology, clarifying the request for help, complaints, functioning and context come first, with your professional formulation in a section of its own. Clinical psychology has its own profile within Hysio with its own documentation formats. Hysio only organises the source information and does not extend any authority. Which consideration about the client's perspective and functioning is recorded follows from your role. [1] [2] [3] [4] [5] [6]
Source-bound documentation makes visible whether a sentence comes from the client, the referrer or the healthcare psychologist. Hysio can place the request for help, course of symptoms and context clearly. The healthcare psychologist guards the professional interpretation, checks where the text belongs in the record and decides which conclusion is or is not justified. That way, a colleague can see where the source ends and your interpretation begins. [1] [2] [3] [4] [5] [6]
Hysio creates the report. You remain responsible for what you save in the record.