AI Progress Note Capture Method: Dictate

We know that as a therapist, your time is best spent with your clients—not buried in paperwork. That’s why we’re so excited about our AI-Assisted Progress Notes. Today, I’m going to show you how to use the Dictation capture method so you can keep your focus where it matters most. This feature allows you to speak your session highlights naturally and watch as our AI transforms them into professional, clinically structured progress notes.

Best Practices for Dictation

To ensure the highest quality notes, follow these clinical documentation standards:

• Maintain Privacy: Always ensure you are in a secure, private location before beginning dictation to protect HIPAA-sensitive information.

• Include Client Response: Explicitly dictate how the client responded to interventions (e.g., "Client expressed relief" or "Client was resistant to the exercise").

• Summarize the "Why": Don't just list activities; dictate the clinical intent behind your interventions to give the AI context.

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Speaking Tips

• Speak Naturally: You don't need to speak like a computer. The AI is designed to understand natural conversational flow and clinical shorthand.

• Enunciate Key Terms: While the AI is robust, clearly pronouncing specific diagnostic terms or medication names helps ensure accuracy.

• Punctuation is Optional: You do not need to say "period" or "comma"—our AI intelligently places punctuation based on your natural pauses and sentence structure.

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Mobile Considerations

• Use the Mobile App: Dictation is even more convenient on your mobile device, allowing you to finish notes immediately after a session while the details are fresh.

• Check Your Connection: For the best experience, ensure you have a stable Wi-Fi or cellular data connection to allow the AI to process your audio in real-time.

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Step-by-Step Guide

1. Access Clients Section

Log in to your dashboard and select the Clients menu.

 

2. Select Client From List

Locate the desired client from your list and click the Client Sessions icon (the two person icon) to access their session history.

 

3. Open Client Sessions

Click the + (Add) button to create a new session entry. From there, continue creating a session as usual. Add the service, select the date of service, and enter the billing code. Click Add.

 

4. Enter Goals & Intervention Details

Select or type the goal and interventions. These will be included in the AI-generated note.

 

5. Activate AI Enhanced Editor

Click the "Enable AI Enhanced Editor" button to activate advanced documentation features.

 

6. Open Dictation Feature

Click the Capture tab, then select the Dictation option.

 

7. Start Dictation

Click "Dictate" to start recording your voice input for the progress note.

 

8. Proceed With Editing

Click the "record" button to start capturing your voice. Ensure you select the correct microphone.

 

9. Advance Editing Options

Additional options are available, including the red trash can for deletion, the yellow pause icon to pause dictation, and the green square to stop dictation and close the dictation window. As you speak, your words will appear in the Capture tab. Filler words such as "um" are automatically removed.

 

10. Generate AI Note

Click "Generate AI Note" to create an AI-assisted summary or enhancement of the progress note content.

 

11. Select Formatting Option

Once the AI note has been generated, click on the formatting options such as "Heading 1," "Bold," or "Smart Edit" to style the progress note.

 

12. Capture Progress Note

Click "Capture" to save the current state of the progress note for further editing or review.

 

13. Open Dictation Feature

Click "Dictation" to access voice-to-text functionality for entering progress note information.

 

14. Start Dictation

Click "Dictate" to begin recording your voice input for the progress note.

 

15. Proceed With Editing

Click here to continue editing the progress note after dictation or other inputs.

 

16. Advance Editing Options

Click here to access additional editing options within the progress note interface.

 

17. Modify Panel Styles

Click the panel body to adjust background color and table styles for better readability.

 

18. Adjust Table Formatting

Click the panel body again to refine table border and collapse settings for the progress note display.

 

19. Generate AI Note

Click "Generate AI Note" to create an AI-assisted summary or enhancement of the progress note content.

 

20. Insert AI Generated Note

Next, you can "Save Progress," "Insert AI Note," or "Discard Changes." Once satisfied, click "Insert AI Note" to transfer the generated text into the official progress record.

 

21. Confirm AI Note Insertion

Click "Insert AI Note" again to confirm and finalize the insertion of the AI-generated note.

 

22. Complete Progress Note Editing

Next, you will notice that your AI-generated content has been incorporated into your progress note. You can now finalize your note as usual.

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Why Use AI Dictation?

Using the dictation feature significantly reduces the "documentation lag" that often follows a long day of sessions. Instead of manual data entry, you can quickly verbalize the encounter, allowing the AI to handle the heavy lifting of clinical synthesis and formatting. This ensures your notes are comprehensive, professionally worded, and completed in a fraction of the time, allowing you to get back to what you do best: helping your clients.