Glossary

The behavioral-health AI-scribe vocabulary — note formats, compliance frameworks, therapy modalities, EHRs, and the terms every buyer should be able to define before evaluating a scribe.

42 CFR Part 2: US federal rule restricting disclosure of substance-use treatment records.
ACT (Acceptance and Commitment Therapy): Third-wave CBT emphasizing psychological flexibility.
AI Scribe: Software that listens to a clinical session and drafts the clinician's note.
Alleva: SUD-native EHR with strong clinical workflow features.
Ambient Documentation: Passive capture of a clinical encounter with no active dictation.
ASAM Criteria: Multidimensional assessment framework for substance-use treatment placement.
ASR (Automatic Speech Recognition): The speech-to-text layer underneath every AI scribe.
AUD (Alcohol Use Disorder): DSM-5 diagnosis for alcohol-related SUD.
AUDIT / AUDIT-C: Alcohol screening instruments.
Audit Trail: Immutable log of who edited a note and when.
Bias / Fairness Audit: Testing note quality across demographic groups.
BIRP Note: Behavior, Intervention, Response, Plan — agency-standard therapy note.
Business Associate Agreement (BAA): Required contract between a covered entity and a HIPAA business associate.
C-SSRS (Columbia Suicide Severity Rating Scale): Standard suicide risk screening instrument.
Case Management Note: Non-therapy contact documentation — coordination, referrals, advocacy.
CBT (Cognitive Behavioral Therapy): Evidence-based therapy modality focused on thoughts, feelings, and behaviors.
Clinical Supervision: Licensed oversight of associate clinicians' work.
Clinician Attestation: The clinician's signature attesting the note is accurate.
Collateral Contact: Documentation of contact with family, providers, or systems on the client's behalf.
Consent to Record: Client permission to record and process session audio.
Couples / Family Therapy: Sessions with two or more related clients.
CPT (Cognitive Processing Therapy): Manualized trauma therapy for PTSD.
CPT Codes: AMA procedure codes used to bill therapy sessions.
Custom Note Template: Clinician- or org-defined note structure the AI must fill.
DAP Note: Data, Assessment, Plan — the default therapy note format.
DAST-10: Drug Abuse Screening Test.
Data Residency: Where PHI is physically stored and processed.
DBT (Dialectical Behavior Therapy): Evidence-based modality developed for borderline personality disorder; widely used in skills groups.
De-identification: Removing identifiers so data is no longer PHI under HIPAA.
Discharge Summary: End-of-episode note summarizing course of treatment and outcome.
DSM-5: Fifth edition of the Diagnostic and Statistical Manual of Mental Disorders.
DSM-5-TR: Current text-revision of the DSM diagnostic manual.
Editorial Independence: Whether a comparison site's rankings are free from vendor payment.
EHR (Electronic Health Record): The system of record for clinical documentation.
EHR Integration Depth: How deeply an AI scribe writes into the EHR.
EMDR: Eye Movement Desensitization and Reprocessing — trauma-focused therapy.
FHIR: HL7's modern healthcare data-interchange standard.
GAD-7: Seven-item generalized anxiety screening instrument.
GIRP Note: Goal, Intervention, Response, Plan — treatment-plan-anchored note.
Golden Thread: The documented line from diagnosis → treatment plan → session note → outcome.
Grounding: Constraining note content to what was actually said in session.
Group Therapy: Therapy delivered to multiple clients simultaneously.
Hallucination: AI-generated content that is fluent but not grounded in the session.
Hallucination Guardrail: Product feature that flags likely fabricated content for clinician review.
HIPAA: US federal privacy law governing protected health information.
HITECH Act: Extends HIPAA breach-notification and enforcement to business associates.
HITRUST CSF: Health-industry security framework with a formal certification.
HL7 v2: Legacy healthcare messaging standard still common in behavioral-health EHRs.
ICD-10-CM: The diagnosis code set required for behavioral-health billing.
IFS (Internal Family Systems): Parts-based psychotherapy modality.
Intake / Biopsychosocial Assessment: First-session comprehensive assessment note.
IOP (Intensive Outpatient Program): ASAM Level 2.1 — 9+ hours per week of structured care.
Kipu: SUD-native EHR common in residential and outpatient addiction treatment.
Level of Care (LOC): ASAM-defined tiers from outpatient to medically managed inpatient.
LLM (Large Language Model): The generative model that drafts the note from the transcript.
MAT (Medication-Assisted Treatment): Medication plus psychosocial treatment for SUD.
Measurement-Based Care (MBC): Routine use of validated instruments to track outcomes in therapy.
Medical Necessity: Payer requirement that services address a diagnosed condition.
Mental Status Exam (MSE): Structured snapshot of a client's current cognitive and emotional presentation.
MITI (MI Treatment Integrity): Coding scheme for measuring fidelity to Motivational Interviewing.
Model Training on PHI: Whether client data is used to improve the vendor's AI models.
Motivational Interviewing (MI): Client-centered therapy for building motivation to change.
MOUD (Medications for Opioid Use Disorder): Current term of art replacing MAT for opioid treatment.
No-Show / Late-Cancel Documentation: Notes required even when the client does not attend.
ORS / SRS: Outcome and Session Rating Scales for feedback-informed treatment.
OUD (Opioid Use Disorder): DSM-5 diagnosis for opioid-related SUD.
PCL-5: PTSD Checklist for DSM-5 — 20-item PTSD self-report.
PHI (Protected Health Information): Individually identifiable health information under HIPAA.
PHP (Partial Hospitalization Program): ASAM Level 2.5 — 20+ hours per week of structured care.
PHQ-9: Nine-item depression screening instrument.
PIRP Note: Problem, Intervention, Response, Plan.
Prior Authorization: Payer approval required before delivering or continuing care.
Progress Note: Per-session clinical documentation of what happened and why.
Prompt Template: The instruction pattern that shapes each generated note.
Psychotherapy Notes: Clinician's personal process notes — separate from the progress note under HIPAA.
Residential Treatment: ASAM Levels 3.1–3.7 — 24-hour non-hospital SUD care.
Risk Documentation: Structured capture of suicide, homicide, and safety risk in the note.
Safety Plan: Stanley-Brown or equivalent structured suicide-prevention plan.
SimplePractice: Popular EHR for solo and small-group behavioral-health practices.
SIRP Note: Situation, Intervention, Response, Plan.
SOAP Note: Subjective, Objective, Assessment, Plan — medical-origin note format.
SOC 2: AICPA audit report on a vendor's security, availability, and confidentiality controls.
Speaker Diarization: Separating who said what across multiple speakers.
Sub-processor: A third-party vendor the AI scribe uses to process PHI.
SUD (Substance Use Disorder): DSM-5 diagnostic category covering addiction-spectrum disorders.
Sunwave: SUD-native EHR and CRM common in treatment centers.
Telehealth: Care delivered over video or phone.
TheraNest: Legacy behavioral-health EHR still common in mid-size practices.
TherapyNotes: Behavioral-health EHR common in solo and group practices.
Treatment Plan: Goal-and-objective document that anchors every session note.
Utilization Review (UR): Payer review of medical necessity for continued SUD treatment.
Valant: Behavioral-health EHR common in medium and larger group practices.
WER (Word Error Rate): Standard metric for speech-recognition accuracy.
Zero-Retention Mode: Vendor configuration where audio and transcripts are not persisted.