Clinical notes are session documentation for a client. Use them to capture observations, treatment decisions, and follow-up plans. Every note is stored encrypted at rest, and only staff with access to the client, whom the note's privacy lets in, can read it.

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

The video shows the note workspace and template editor using fictional Riverstone data. Its example answers are written manually in the template preview and are not saved to a client's chart. For recording and transcription, see AI Scribe.

Create a note

Open the client's profile and find the Clinical Notes section.
Click Add Note and choose the visit, or Not for a specific visit.
Check the template at the top of the note. A service can have its own starting template; you can choose another or use No template.
Write in the note's fields. The visit and client context stay alongside your work.
Check the save indicator before leaving. The workspace saves a draft as you write. Review the note before choosing Sign note.

You can also choose Start note from an appointment or pick a visit in Notes to finish on your dashboard.

Note types and formats

Templates with sections can combine text, choices, chips, scales, checklists and body charts. Their labels and fields follow the template your practice has chosen.
Classic notes use SOAP, DAP, progress or narrative formats. SOAP groups the note into Subjective, Objective, Assessment and Plan; DAP uses Data, Assessment and Plan.

Build and preview the structure on the Note Templates page; see Note Templates.

Speed up note-writing

Two AI options help here:

Expand with AI turns rough notes into a structured SOAP, DAP, or progress note. See AI Note Expansion.
AI Scribe records dictation or a full session and drafts the note from it. See AI Scribe. It's a per-practitioner add-on, not bundled in any base plan.

Draft, finalized, signed, locked

Each note shows its status:

Draft: saved but not finished. Edit it any time.
Finalized: marked complete, and still editable.
Signed: click Sign note on a draft or finalized note to certify it's accurate and complete. A signed note can no longer be edited. The workspace saves pending edits before signing; resolve any save warning before continuing.
Locked: an owner or admin can lock a signed note so it's permanently read-only.

Draft and finalized notes can be deleted. Signed and locked notes can't.

Who can read a note

Reading a note takes two things: access to the client (see client access in Team Management), and a note privacy that lets you in. Each note shows who can read it next to its status. Its author can change that for the one note:

All staff. Everyone on the team who can see the client. Every note starts here unless its author chooses otherwise.
Staff in my discipline. Staff who share the author's discipline, plus owners and admins. An owner or admin sets each practitioner's discipline under Credentials on the Practitioners page.
Only me. Nobody else. Owners and admins can't read it either, unless the author shares their notes with them.

Each practitioner sets the default for new notes, and can share all their notes with named colleagues, under Notes in their settings. Owners and admins can change a practitioner's default from the practitioner's panel, and can take someone off their share list, but only the practitioner can add someone to it. Every change, and every attempt to open a note someone can't read, is recorded in the audit log.

Owners and admins can't open, edit, sign or delete a note they can't read. The client's chart tells them how many of its notes are private, and your practice's full data export always includes every note.

Psychotherapy notes are separate: only the practitioner who wrote one can read it, whatever these settings say.

Manage notes

Click a note in the client's Clinical Notes list to view or edit it.
Notes are listed on each client's profile. They aren't included in the search bar at the top of the app, so to find a note, search for the client and open their profile.
The save indicator tells you whether your latest changes are saved. If it shows Not saved, retry and resolve the warning before leaving the workspace.

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.

Clinical Notes