Diagnosis and treatment plans

Practice Harbor lets you add diagnoses to a client's chart using standard ICD-10 codes and create treatment plans — either manually or with AI assistance. There is no limit to how many diagnosis and treatment plan entries you can create for a client.

In this guide, we'll cover:

• Adding a diagnosis
• View mode
• Creating a treatment plan
• Load previous plan
• ICD-10 diagnosis codes
• Client signatures
• Tips

Adding a diagnosis

1. Navigate to the client's chart
2. Click New and select Diagnosis and treatment plan
3. In the Diagnosis code dropdown, search for an ICD-10 code by typing the code (e.g., "F32.1") or a keyword (e.g., "depression")
4. The dropdown displays the full code and description (e.g., "F32.1 - Major depressive disorder, single episode, moderate")
5. Once you select a code, the Description field auto-populates with the diagnosis name — you can edit this text if needed
6. Set the Date and time of diagnosis (defaults to the current date and time)
7. Click Save (the button reads Update when you're editing an existing entry)

Adding multiple diagnoses

You can add multiple diagnoses to a single entry:

1. Click the + (plus) button next to any diagnosis row to add another row
2. Select a code and adjust the description for each row
3. To remove a row, click the trash icon next to it (if only one row remains, the trash icon resets it instead of removing it)
4. Click Save to store all diagnoses at once

All diagnoses in an entry share the same date and time.

Skipping the diagnosis

If you want to go directly to a treatment plan without entering a diagnosis, click the Skip to treatment plan link at the bottom of the diagnosis form.

View mode

After saving your diagnoses, the page switches to a read-only view. From here you can:

• Sign — Click the Sign button to attest the diagnoses (your name and the signing time are recorded on the entry) and return to the client's chart.
• Edit — Click the pencil icon to return to edit mode with your saved diagnoses pre-populated.
• Print — Open the More menu (three-dot icon) and select Print to print the diagnosis summary.
• Download — Open the More menu and select Download to save a text file summary of the diagnoses.
• Delete — Open the More menu and select Delete to remove all diagnoses in this entry and return to edit mode.

Creating a treatment plan

After saving diagnoses, a Treatment Plan template picker appears in view mode. You have two options (three, if your practice has built its own form):

Simple template

Select Simple from the template picker to open a straightforward text-based treatment plan form.

1. Your saved diagnoses carry over automatically with their ICD-10 codes and descriptions
2. Optionally enter a Treatment plan title (e.g., "Initial Treatment Plan")
3. Write your treatment plan in the Treatment plan text area — document measurable objectives and interventions
4. Click Save Treatment Plan

The Simple template is ideal for quick, free-form documentation.

Advanced template with AI

Select Advanced with AI from the template picker (or navigate to the treatment plan page directly) to access the full-featured treatment plan editor. The Advanced template has two tabs:

Generate Treatment Plan Tab

This tab lets AI create a structured treatment plan based on your inputs:

1. The plan's diagnoses come from the Diagnosis page — "Diagnoses are entered on the Diagnosis page. To add or change one, edit it there." (Arriving from the diagnosis view carries them automatically.)
2. Leave Use AI to generate treatment plan on, and choose a Therapy Approach (CBT, DBT, ACT, Psychodynamic, Solution-Focused, or General)
3. Select Focus Areas relevant to the client (Depression, Anxiety, Trauma, Relationships, Coping Skills, and more)
4. Optionally add Additional Instructions for the AI
5. Click Generate with AI
6. The AI creates a structured plan with goals, activities, and assessments, ready for review on the Edit Plan Details tab

Edit Treatment Plan Tab

This tab displays the structured treatment plan with editable sections:

• Goals — What the client is working toward, each with a lifecycle status (Proposed, Planned, Active, Completed, etc.)
• Activities/Interventions — Therapeutic approaches and specific interventions, each with a status (Not Started, In Progress, Completed, etc.)
• Assessments — Clinical measures and evaluations to track progress
• Plan title and notes — Overall plan metadata

You can manually add, edit, or remove goals, activities, and assessments. Each section has + buttons to add new items and trash icons to remove them.

Generate with AI button

When creating a new treatment plan (not editing an existing one), the Generate with AI button appears in the top-right corner of the page. Click it to have the AI generate a structured treatment plan based on the client's diagnoses and your selected options. The generated plan populates the Edit tab where you can review and modify it before saving.

tip

For best results with AI generation, select specific diagnoses and focus areas rather than leaving them blank. The more context you provide, the more tailored the generated plan will be.

Your practice's own form

If your practice has built its own treatment plan form, it appears in the template picker under Simple and Advanced, labelled Your practice's form. Choose it to fill the plan in by clicking through the form: checkboxes, pick-one lists, dates and text boxes, in the sections your practice set up.

1. Your saved diagnoses carry over, as they do on the other templates
2. Work through each section of the form
3. Check the review reminder. If the form sets a default (for example, in 180 days), it is already filled in and you can change it for this plan
4. Click Save. You can save a partly finished plan and come back to it

A plan written on a form is signed, co-signed, sent for client signature and printed like any other plan. Fields the form marks as required must be answered before you can sign; they never stop you from saving. Revising the plan later reopens the same form with the previous answers copied forward.

Generate with AI on your own form

On a plan written on your practice's form, Generate with AI suggests answers for the form instead of writing a plan for you:

1. Click Generate with AI at the top of the page. It reads this client's diagnoses, recent notes and transcripts, intake note and previous treatment plan. It never reads another client's record
2. Each suggestion appears under its field, marked Suggested. Click Accept on the ones you want, Accept all for a section, or Accept all suggestions at the top of the form
3. Change anything you like, then click Save

Nothing is added to the plan until you accept it, and suggestions you have not accepted are not saved. A field you have already answered gets no suggestion. Fields about the client, such as presenting problems or strengths, are suggested only when the record supports them; goals, objectives and interventions are drafted for you to edit. Anything recording the client's participation, agreement, consent or signature is never suggested; only you were in the room. Risk questions, such as suicide or self-harm, are suggested like any other field when the record supports them, and like any other field nothing is recorded until you accept it. A client with little history gets few suggestions.

To build a form, see Treatment plan forms.

Load previous plan

If the client has existing treatment plans, a Load Previous Plan button appears next to the Generate with AI button. Click it to see a dropdown of up to 5 previous plans (active, draft, or completed). Selecting a plan loads it into the editor so you can review or update it.

This is useful when you want to build on a prior plan rather than starting from scratch.

ICD-10 diagnosis codes

Practice Harbor includes a curated library of ICD-10 mental health diagnosis codes (383 codes) organized by category:

Category	Code Range	Examples
Depressive Disorders	F32-F34	Major depressive disorder, Dysthymia, PMDD
Bipolar Disorders	F30-F31	Bipolar I, Bipolar II, Cyclothymia
Anxiety Disorders	F40-F41	Generalized anxiety, Social anxiety, Phobias
Trauma and Stress-Related	F43	PTSD, Acute stress, Adjustment disorders
OCD and Related	F42	OCD, Body dysmorphic disorder
Substance Use	F10-F19	Alcohol, Opioid, Cannabis use disorders
Eating Disorders	F50	Anorexia, Bulimia, Binge eating
Personality Disorders	F60	Borderline, Narcissistic, Antisocial
Neurodevelopmental	F84, F90	Autism spectrum, ADHD
Other	Various	Insomnia, Sexual dysfunction, Relationship problems

The diagnosis code search supports searching by code number or description text.

note

ICD-10 codes are updated annually on October 1st. To confirm a code is current and billable, you can check the ICD-10 database.

Printing or downloading a plan

Any loaded plan has Print and Download PDF buttons — the PDF includes diagnoses, treatment frequency, goals, interventions, assessments, and every signature on the plan (including the client's e-signature and a supervisor's co-sign). Drafts print too; the PDF states the plan's status.

Deleting a plan

You can delete a treatment plan that isn't signed:

• On the plan page, click Delete next to Print and Download PDF.
• On the client's chart, click the red trash icon on the plan's card, next to the edit icon.

Confirm in the dialog. Deleting removes the plan, its goals and its comments permanently and cannot be undone.

A signed plan shows no Delete. Unlock it first (you'll be asked for a reason), then delete it. A plan that is awaiting your supervisor's co-signature can't be deleted or unlocked until your supervisor co-signs it. A plan that AI is still writing can be deleted once it has finished.

Keeping an eye on plan status practice-wide

Analytics has a Treatment plans ring on the dashboard (your active caseload's plan coverage at a glance) and a Treatment plans report — one row per client showing whether their current plan is signed, awaiting co-sign, awaiting the client's signature, unsigned, or missing, with review-due dates highlighted when overdue. Filter by status or export to CSV. See Analytics reports.

Client signatures

Once a treatment plan is fully signed (including your supervisor's co-signature, if you have one), you can invite the client to sign it electronically:

1. Open the plan and click Request client signature (it appears next to Unlock once the plan is signed — also available on the plan's card in the client's chart).
2. The Share Documents flow opens with the plan pre-selected. For minors you'll choose which parent/guardian should receive it; for couples and families you'll choose which members sign — each selected person gets their own copy to sign.
3. Review the notification email and send. The plan appears in the client portal under Documents, marked optional.
4. The client (or guardian) reviews a frozen copy of the plan, checks an attestation ("I have reviewed this treatment plan, participated in its development, and agree with its goals…"), and types their name to sign.
5. You're emailed when they sign, the plan shows a Client signed badge, and their signature line appears alongside yours ("Signed by … (client)").

A few things worth knowing:

• Signing is always voluntary for the client — it's presented that way, and it's never a required checklist item. An unsigned request just waits; nothing depends on it.
• The copy is frozen at the moment you share it. Later edits to the plan never change what the client signed — their signed copy remains available verbatim in their portal Documents.
• Unlocking a plan cancels any un-signed requests automatically, so a client can't sign an outdated copy. After re-signing the revised plan, request a new client signature if you want one.
• Client signatures aren't required by most payers — but they're the cleanest evidence of the client's participation in treatment planning, which some Medicaid programs do require you to document.

Tips

• You can save a diagnosis without creating a treatment plan, or create a treatment plan without a diagnosis — both workflows are supported.
• Signing a diagnosis records your attestation (who signed, and when) on the entry — see Diagnoses for what signing does and doesn't change.
• The downloaded diagnosis summary is a plain text file named with the current date (e.g., diagnosis-summary-2026-03-22.txt).
• Treatment plans are stored as FHIR CarePlan resources, making them interoperable with other healthcare systems.

Related

• How AI notes work
• Magic Edit
• Adding a client