What to Include for Better Notes – Checkpoint EHR

We know that as a provider, your time is best spent in the "heart of the work"—connecting with your clients and supporting their journey toward wellness. You shouldn’t have to choose between being fully present in a session and worrying about the paperwork that follows.

That’s why we’re so excited about our AI-Assisted Progress Notes. To help you get the most out of this feature, we’ve put together this guide on how to provide the "clinical signals" the AI needs to draft high-quality, substantive, and compliant notes.

Clinical Therapy Notes: Capturing Medical Necessity

For clinical notes (such as SOAP or DAP formats), the AI looks for specific diagnostic and intervention-based language to ensure the note meets insurance standards and medical necessity.

What to State Aloud or Include in Summaries:

The Clinical Intervention: Explicitly name your modality so the AI can categorize the work correctly.
- Example: "Today, we used Cognitive Behavioral Therapy (CBT) to challenge those automatic thoughts."
Mental Status Observations: Since the AI can’t "see" the client, verbally narrate key observations if they are significant.
- Example: "I noticed your affect appears much brighter today."
Risk Assessment: Always verbally confirm safety if it is a focus of the session.
- Example: "I’m glad to hear you are still denying any suicidal ideation."
Homework & Follow-up: Clearly state the plan for the next session.

Peer Support Notes: Moving from "Thin" to "Substantive"

Peer support documentation is unique in its focus on lived experience and empowerment. To ensure your notes are meaningful and compliant, the AI needs enough "signal" to distinguish the work from clinical services.

1. The Essential "Four" (Minimum Requirements)

To produce a valid note, ensure your session or text summary covers these four bases:

The "Why": Why did the client want peer support today?
The Action: What is at least one specific thing you did together?
The Response: How did the client respond or what shifted during the session?
The Future: What happens next? (Client plan and/or follow-up).

2. Making Your Notes Even Stronger

When possible, include these details to provide a more "substantive" picture of the peer’s progress:

Name the Tool: Use specific names for skills or strategies (e.g., "Box Breathing" or "Housing Application Checklist") rather than just "coping skills."
Describe the Application: How was the skill used? Did you practice it, role-play a conversation, or plan for future use?
Highlight Strengths: Mention a specific positive effort or strength the client demonstrated.
Define the Timeframe: Set a clear deadline for next steps (e.g., "by Tuesday" instead of "soon").

3. Bridge the "Goal Gap"

The AI doesn’t have direct access to your offline Treatment Plans yet. To be fully compliant, the note must connect today’s activity to a larger goal.

How to do it: Simply mention the goal name aloud or include it in your summary.
- Example: "This supports your Employment Goal in your recovery plan."

Why Quality Input Matters

This feature is a gamechanger for clinical efficiency. By providing clear clinical signals, the AI handles the heavy lifting of clinical synthesis. This ensures your notes remain professional and comprehensive without the manual burden of starting from a blank page every time.