This article provides an overview of how Measurement-Informed Care (MIC) is integrated into clinical documentation for the initial assessment and progress notes and how to utilize MIC data in sessions with patients.
MIC in the Initial Assessment
The Initial Assessment serves as the foundation for identifying treatment needs, establishing a diagnosis, and determining fit. As such, information from the measurement surveys is invaluable.
If the patient has completed the measurement surveys (e.g., GAD-7, PHQ-9, etc.) this will be integrated into the “Measures” section of the Initial Assessment note. Scores are color-coded and plotted on a severity scale which will help you quickly spot trends and notable shifts in self-reported behavior.
Here you see an example of an Initial Assessment note:
MIC in Progress Notes
Completed measurement surveys will be integrated into progress notes and can be seen in the “Measures” section of the note.
Several past surveys are visible as well for comparison (the baseline survey and—if applicable—the most recent previous survey). This means up to three surveys may be present (Baseline, Previous session, This session). Scores are color-coded and plotted on a severity scale which will help you quickly spot trends and notable shifts in self-reported behavior.
Here you see an example of the measurement survey results in a signed note:
Utilizing MIC in sessions with patients
When completing documentation for an Initial Assessment or Progress Note, you'll be prompted to confirm whether you reviewed the patient's measures within the past 14 days. You’ll also need to select an action from a dropdown menu.
Here you see where you would indicate whether you reviewed the measures and the dropdown menu of actions:
If a patient has not completed the measures for this session or the previous session, you'll not be asked to select whether you reviewed the measures with your patient. Instead, you'll see a message that indicates measures haven't been completed in the last two weeks.
A note on Kaiser patients
Please note that the MIC cadence for Kaiser patients is changing, rolling out in phases between June and July 2026. Kaiser patients will be prompted to complete certain measures (Quality of Life (QoL), Therapeutic Alliance (TA), C-SSRS / Child C-SSRS (Kaiser SoCal ONLY), PHQ/GAD/PROMIS Depression/PROMIS Anxiety (Kaiser NCAL ONLY)) before each visit or once a week, depending on the patients coverage (unless they have already completed one within the last 3 days). Following these rules is a contractual requirement that protects the patient's insurance coverage and enables consistent tracking of their clinical progress.
Patients may feel frustrated or overwhelmed by how often they are asked to complete these surveys, but Kaiser administrators use these measures to track their progress and ensure network compliance. Remain empathetic and continue to create a safe space for questions and concerns, even related to MIC survey frequency.
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