Clinical Notes

Clinical notes are session documentation tied to a specific appointment and client. Use them to capture observations, treatment decisions, and follow-up plans. Every note is stored encrypted at rest and only readable by practitioners with access to the client.

Notes are available on Solo and above. In the US, full PHI handling and the audit log require HIPAA mode (see HIPAA Compliance).

Create a note

1. Open the client's profile and go to the Notes tab.
2. Click New Note.
3. Pick a template (SOAP, DAP, free-form, or one of your custom templates).
4. Write your observations.
5. Click Save.

SOAP, DAP, and free-form

SOAP and DAP are pre-built templates with defined sections:

• SOAP: Subjective (what the client reports), Objective (what you observed), Assessment (your read), Plan (next steps).
• DAP: Data (what happened), Assessment, Plan.
• Free-form is a blank canvas with no sections.

You can also build your own templates from the Note Templates page; see Note Templates.

Speed up note-writing

Two AI options help here:

• AI Note Expansion turns a quick bulleted summary into a structured note. See AI Note Expansion.
• AI Scribe records dictation or a full session and generates the note from the transcript. See AI Scribe. It's a per-practitioner add-on, not bundled in any base plan.

Manage notes

• Click a note in the client's notes list to view or edit it.
• The search bar searches across all your notes (within your access scope).
• Notes are timestamped and link back to the appointment they belong to.

Tips

• Write notes promptly after the session for the most accurate capture.
• Templates save time and keep your documentation consistent across the practice.
• If you bill insurance, write your notes with the procedure and diagnosis codes you'll claim, so the documentation supports the codes.