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Creating a manual or blank note

Create a note manually and use templates or shortcuts to structure it.

Create a blank note when you want to document care manually instead of using a session transcript.

When to use a blank note

A blank note can be useful when:

  • The patient did not consent to transcription.

  • You are documenting care coordination, a phone consultation, or an insurance follow-up.

  • You need to record an observation or incident outside a scheduled session.

Create a blank note

To create a note:

  1. Select Notes in the left sidebar.

  2. Select the patient.

  3. Select Create Note.

  4. Select Start with a blank note.

Add a SOAP or BIRP structure

To add a built-in structure:

  1. Enter / in the note editor.

  2. Select Generate Template.

  3. Choose a format, such as SOAP or BIRP.

  4. Add your clinical information under each heading.

Create another structure with the AI Assistant

For a different document, ask the AI Assistant to create the headings. For example, enter Create a template for a Psych Intake Evaluation.

Review the generated structure, then add the patient-specific information.

Use note shortcuts

While editing, enter /dx to add the patient’s diagnosis or /rx to add their current medications.

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