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.

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

3. Click the Add icon (plus sign).

4. Complete the session details and then select Add.

5. If applicable, select Goals and Interventions.

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

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."

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.

Upload a File: You can upload a session Transcript or an audio Recording.
- Select the appropriate tab (Transcript or Recording).
- Click Choose File to select a file from your computer.
- 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.

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.

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.

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.



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.

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.


Related Articles
Why Use AI-Assisted Progress Notes?
Best Practices for Implementing AI
Comments
0 comments
Article is closed for comments.