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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.

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)

The diagnosis entry form with the ICD-10 code dropdown

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.

Two diagnosis rows with the code picker open on the second

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.

The saved diagnosis in view mode with Sign, edit, and the More menu

Creating a Treatment Plan​

After saving diagnoses, a Treatment Plan template picker appears in view mode. You have two options:

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.

The Simple treatment plan form with the diagnosis carried over

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

The Generate Treatment Plan tab with therapy approach and focus areas

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.

The Edit Treatment Plan tab with plan details

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.

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.

The Load Previous Plan dropdown listing a saved plan

ICD-10 Diagnosis Codes​

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

CategoryCode RangeExamples
Depressive DisordersF32-F34Major depressive disorder, Dysthymia, PMDD
Bipolar DisordersF30-F31Bipolar I, Bipolar II, Cyclothymia
Anxiety DisordersF40-F41Generalized anxiety, Social anxiety, Phobias
Trauma and Stress-RelatedF43PTSD, Acute stress, Adjustment disorders
OCD and RelatedF42OCD, Body dysmorphic disorder
Substance UseF10-F19Alcohol, Opioid, Cannabis use disorders
Eating DisordersF50Anorexia, Bulimia, Binge eating
Personality DisordersF60Borderline, Narcissistic, Antisocial
NeurodevelopmentalF84, F90Autism spectrum, ADHD
OtherVariousInsomnia, 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.

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.