Writing a clinical note

You can start a clinical note from almost anywhere a session appears — the Today view, your dashboard, the calendar, a client’s record, or your outstanding-notes list. They all open the same note editor.

SOAP or unstructured

New notes can use one of two formats:

• SOAP — structured into Subjective, Objective, Assessment and Plan, in collapsible sections.
• Unstructured — a single free-text note.

Caution

The format is chosen when you create the note and locks after the first save — you can’t switch a note between SOAP and unstructured later, so pick the one you want up front.

Note types

Notes are typed: Session, Assessment, Progress, Discharge or General. When you open a note from an appointment, the type is chosen for you based on the appointment type, and the default format follows the type.

Details filled in for you

When a note is linked to an appointment, the session date, time, duration and note type are pre-filled, and an indicator shows it’s linked. You can record attendees and, in a team practice, the authoring therapist.

SOAP notes also have dedicated fields for goals addressed, activities and materials used, and additional notes.

Rich text and @-mentions

The editor supports rich text and @-mentions — type @ to insert a token for the client, therapist, guardian or session date, which fills in automatically. This keeps notes accurate and quick to write.

Once you’ve written the note, you can save it as a draft or sign it — see Signing and locking notes.