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Creating a Progress Note with AI Assistance

Updated

This guide will walk you through the steps of creating a progress note using our AI-Assisted features helping you save time while ensuring your documentation is comprehensive and accurate.

 

Getting Started

1. From the navigation menu, select Clients.

Select the "Clients" menu.

 

2. Select the Client Session icon (two people).

Select the Client Session icon (two people).

 

3. Click the Add icon (plus sign).

Select Add icon (plus sign).

 

4. Complete the session details and then select Add.

Complete the Session information and then select Add.

 

5. If applicable, select Goals and Interventions.

Select Goals and Interventions, if applicable.

 

6. From any progress note screen, select Enable AI Enhanced Editor to launch the tool.

Click on Enable AI Enhanced Editor

 

Inputting Session Information

The AI editor provides several ways to input information about your session.

Type a Draft: In the Draft section, type the content for your progress note.

  • Tip: You don't need to write perfect sentences. The AI is designed to handle grammar, structure, and clinical language. Use natural language and phrases, like "kid was really engaged today, loved the puzzle activity."

Type in the content of the progress note in the "Draft" section.

 

Dictate a Note: Select the Dictate button. A dictation box will appear in the upper right where you can use the controls to record, pause, and stop your dictation. Your spoken words will appear in the Draft section.

If you would rather dictate the note, select "Dictate".

 

Upload a File: You can upload a session Transcript or an audio Recording. 

  1. Select the appropriate tab (Transcript or Recording).
  2. Click Choose File to select a file from your computer.
  3. Select Upload.

Another option to add information about the session is to upload a transcript. Select the transcript tab and then the input source. You can upload a file or paste text from a transcript. Once the input is selected, select Choose File, select the file then select "UPload".

 

Generating and Editing the Note

Once your session information is entered, you can generate and refine the note.

 

7. Select Generate AI Note. The system will process your input and create a structured clinical note in the right-hand panel.

When finished either writing, dictating or uploading files, select "Generate AI Note"

 

8. Review the generated note. You can use the toolbar at the top for basic edits, such as undo/redo, bold, italics, or bullet points.

Some basic editing options are at the top.

 

9. For more advanced revisions, select Smart Edit. This tool allows you to apply pre-set commands (e.g., Improve Clarity, Make Professional) or enter your own custom instructions to refine the text.

Select "Smart Edit" to make even more power changes.

 

10. After selecting a Smart Edit option, a new window will show the Original Text and the Improved Text. Review the suggestions and select Apply Changes to accept them.

You can select from pre-designed improvement changes or type up your own!

If you select a pre-designed option, the AI-Enhancement tool will expand and automatically start working. Your original text will appear at the top and then improved text at the bottom.

Select "Apply Changes" and the changes will be applied to the AI-Enhanced section.

 

Finalizing and Inserting the Note

After editing is complete, you have three options at the bottom of the editor:

  • Save Progress: Saves your work within the AI editor for later.

  •  

    Insert AI Note: Moves the final AI-generated content into the standard progress note field.

  •  

    Discard Changes: Deletes the AI-generated content and closes the editor.

After all changes are made in the AI-Enhancement section, you have a few options.

 

11. If you choose Insert AI Note, a confirmation box will appear. Select Insert AI Note again to finalize the action. The AI-Assisted text will now populate the main progress note text box.

If you select "Insert AI Note" you will receive a confirmation box. Select "Insert AI Note" to finalize.

Your AI-Enhanced progress note will be inserted into the Progress text box.

 

Related Articles 

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Input vs. Output Comparison

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