The Notes tab on a client's profile is the clinical workspace. It is called Notes for behavioral health practices, Clinical notes for medical ones, and Psychotherapy notes for therapy-only practices.
The Notes tab
- A strip of tiles at the top shows only what needs you: a visit without a note, the treatment plan's state, the latest measure or an unacknowledged risk flag, and any note waiting for your co-signature. When nothing is outstanding it reads "All caught up".
- The pill row switches between Notes, Treatment plan, and Measures.
- The toolbar has a kind filter (All, Clinical, Psychotherapy), an attention filter (All notes, Needs attention, Drafts, Signed), a ⋯ menu (Export this client's chart (PDF), which is the notes only; Export whole practice (ZIP); Manage templates), and a New note split button offering Clinical note, Psychotherapy note, and Discharge summary.
- Notes are listed by month with a status pill (Draft, Pending cosign, Signed, Amended, Void) and the next step on the right (Continue, Cosign, Open). With no notes yet you see a first-session checklist: start the plan, write the first note, send a baseline measure.
Start a note
- New note on the Notes tab.
- Write note on a Note due task (Tasks → Clinical), or on a visit in the strip at the top of the Notes tab.
- Add Note on an appointment in the calendar editor, which opens the editor over the calendar.
- Start clinical note on the ended screen of a video visit.
The editor
The top bar shows the note type, the client's name and date of birth, the linked visit, and the autosave status ("Saved 12 seconds ago"). Drafts save on their own a moment after you stop typing.
On the left, a context rail:
| Card | What is there |
|---|---|
| Visit | Link or change the visit while the note is unsigned, set attendance (Show or No-show), see the previous and next visit, the visit's fee and whether it is paid, and open billing or the calendar. |
| Safety | Allergies and medications from the record. |
| Previous note | Open it, or Copy into this note while drafting. |
| Plan goals | Open the treatment plan, or start one. |
The note type is Progress, SOAP, or Discharge, with a Template dropdown beside it. Built-in sections are one Note for progress; Subjective, Objective, Assessment, Plan for SOAP; and presenting problem, course of treatment, outcome, recommendations, and referrals for a discharge summary. Sections take rich text: bold, italic, lists, links, dividers.
A clinical note ends with Treatment progress: rate each active objective 0 to 10 with a comment, and the ratings are stored on the treatment plan when you save. The panel also shows the latest outcome measure scores.
The footer holds Save draft and Sign and lock while drafting, Edit on a saved draft, and a More menu: delete draft, add a psychotherapy note for the same visit, request an amendment, void.
Draft with AI
When the practice has turned on AI progress notes (Pro and above), a collapsible Draft with AI card sits above the sections while you edit a clinical note. Type a short recap of the session, dictate one, upload a recording, or start live note-taking during the visit, and Draft note fills in the sections of the template you chose. The draft is marked AI-assisted, no audio is stored, and you review every section before signing. Psychotherapy notes never get AI drafting. See AI progress notes for consent, minutes, and what is and is not kept.
Sign and lock
Sign and lock asks for your name and credentials and shows a preview of the signature. When the note was drafted with AI, the dialog carries the line "I have reviewed this AI-assisted draft and it reflects my clinical judgment", and signing stamps you as the reviewer. Once signed, the note is locked: its content is fingerprinted, edits are refused, and only two things can happen to it:
- Add addendum: appended with its own time; the note shows as Amended.
- Void, with a required reason; the note stays in the record marked void.
If your provider record is set to require a co-signature, the note shows Pending cosign and your supervisor is notified; see Notes due and co-signatures. Signing a note linked to an appointment also captures the visit's charge.
A nightly integrity sweep re-checks every locked note's fingerprint; a note that fails is flagged in the editor, kept read-only, and left out of exports.
Templates
Manage templates in the Notes tab's ⋯ menu (or Manage templates… in the editor's Template dropdown) opens the note templates: a name, a type (SOAP, Progress, or Intake), and the list of sections. Built-in templates are read-only; yours can be edited or removed. Behavioral health practices also get built-in DAP, BIRP, and GIRP progress-note templates and an Intake assessment template. Physical therapy clinics get PT daily note, PT initial evaluation, PT progress note / re-evaluation, and PT discharge summary; see FrontDesk for physical therapy clinics. Your practice type's templates are listed first in the dropdown, then the generic SOAP note and Progress note, then your own; other practice types' templates are hidden.
Psychotherapy notes
A psychotherapy note is the therapist's private process note, stored apart from the chart:
- Only its author can open it. An owner or admin sees a locked stub with the author's name and can break the glass in an emergency: a reason is required, access lasts 24 hours, and the event is written to the HIPAA Audit Log (Settings → Account Activity).
- It never appears in a chart export, a release, or the data file, whatever a release form says, and signing it does not capture a charge.
- It has no Discharge type and no treatment-progress section. Its banner reminds you it is kept separate.
Who can do what
| Action | Who |
|---|---|
| Read clinical notes | Owner, admin, manager, provider |
| Write, edit drafts, manage templates | Anyone with a provider identity on their login |
| Sign | The note's author only |
| Co-sign | A different licensed provider or admin, never the author |
| Read a psychotherapy note | Its author (a supervisor may read one to co-sign it) |
Every view, edit, signature, and export is written to the HIPAA Audit Log under Settings → Account Activity, and adding, signing or co-signing a note also shows in its History tab.