Clinical Notes & Care

Progress notes, treatment plans, outcome measures, co-signatures, discharge, and records release.

• Write and sign clinical notesClinical notes live on the client's Notes tab. Start one from the New note button, a completed visit, or the calendar; write it in sections from a built-in layout or your own template while it autosaves, or let the Draft with AI card write the first draft from a recap, dictation, an upload, or live note-taking; then sign and lock it with your name and credentials. A signed note cannot be edited. Add an addendum or void it with a reason. Notes by associates wait for a supervisor's co-signature. Psychotherapy notes are a separate, author-only record that never leaves the practice in an export. Signing a note linked to a visit also captures the visit's charge.
  5 min
• AI progress notesAI progress notes draft a clinical note in your template from the session. Turn them on in Settings → Clinical Settings (Pro and above) with Draft notes with AI and, for listening during visits, Live note-taking during visits. While editing a note, the Draft with AI card offers Recap (typed, not metered), Dictate, Upload (an audio file) and Live; a video visit's More menu has an AI notes item. Live note-taking needs your attestation that the client agreed. No audio is stored, the transcript is discarded once the draft exists, and the note you sign is marked AI-assisted. Dictation, uploads and live sessions use AI note minutes: Pro 300 a month, Elite 1,000. Psychotherapy notes and group sessions are not supported.
  6 min
• Add diagnoses to a client's recordDiagnoses live in the Diagnoses (ICD-10) section of the Clinical card on the client's Overview tab. Click Add diagnosis, search by code or description (F41.1 or "anxiety") and pick the match, click Set primary on the main one, and Save; if none is marked, the first row is primary. The order of the rows matters: superbills print the diagnoses lettered A, B, C in that order, and each charge points at those letters. Diagnoses are encrypted at rest, copied into a new treatment plan, and included in chart exports. Any team member who can edit the client can edit them, and every change is written to the HIPAA Audit Log (Settings → Account Activity).
  1 min
• Notes due and co-signaturesFrontDesk keeps a notes-due list (every completed visit without a signed note) on the Tasks page under Clinical, with a Write note button and a "No note needed" option for admin visits. A daily job nudges the provider once when a visit passes the practice's threshold (48 hours by default). Providers marked as associates or interns have their notes wait as "Pending cosign" until the supervisor named on their profile co-signs; supervisors get a task and a reminder every 7 days. Both signatures print on the chart export. The Note reminders switch and both timers live on the Clinical Settings page under Settings → Clinical Settings.
  3 min
• Treatment plansA treatment plan lives on the client's Notes tab as a document you edit in place. Start it prefilled with the client's diagnoses, add goals with objectives and interventions, and sign it to activate it, which freezes the text and starts a review cycle (90 days by default). Send it to the client to sign in their portal by typed name, or record an in-person agreement. Each progress note carries a treatment-progress panel where you rate objectives 0–10, and the plan shows the trend. Reviews push the review date forward; overdue reviews appear on the Tasks page. Revising creates a new signed version with the old one kept.
  3 min
• Outcome measures (PHQ-9, GAD-7, pain and function scales)FrontDesk includes 13 scored measures: PHQ-9, GAD-7, PCL-5, AUDIT, AUDIT-C, DASS-21 and the C-SSRS screener for mental health and primary care, and NPRS, LEFS, UEFI-20, Roland-Morris, ABC and Berg Balance for physical therapy. Those suited to your practice type are listed first under Recommended for your practice. Send one from the client's Notes tab → Measures (they complete it by link or in their portal, no login needed for the link), or click Enter in session. Berg is clinician-scored and can only be entered in session. Scores and bands are calculated on completion and trended; a worrying answer (PHQ-9 item 9, PCL-5 item 16, DASS-21 item 21, C-SSRS item 2 or a high-risk C-SSRS, Berg 45 or below) raises a risk flag that notifies the provider and stays on the Tasks page until acknowledged. A schedule sends the next one automatically: before or after visits, or every week up to every three months. Clients never see their scores.
  6 min
• Discharge, records release, and chart exportThe client's Records tab handles the end of care and the sharing of records. Discharge closes the treatment plan and measure schedules and marks the client discharged (reversible). A release of information is drafted with recipient, purpose, scope, and expiry, signed by the client in the portal or on paper, and then used to export the chart as a scoped PDF, which records a disclosure automatically. Disclosures made outside the app can be logged by hand, and the accounting of disclosures is available as a PDF for the client, who can also download a copy of their record from the portal. Psychotherapy notes are never exported.
  3 min