Documentation and notes
Quick Dictate and Sefton Voice
Dictate the note while you talk, review the suggested ICD-10 and CPT® codes with confidence scores, add modifiers, link goals, and sign. Plus booking, billing, and signing by voice.
Quick Dictate is where a visit becomes a signed, coded note. Sefton Voice is the same engine driving the rest of the practice by speech.
Dictating a note
- Open Quick Dictate from the session card or the Sessions floating button. Pick the patient and appointment (or Open from meetings after a telehealth visit).
- Press record and talk through the session, or type into the note field. A template from your library can be loaded first.
- Sefton drafts the SOAP note as you speak and flags Diagnosis detected and Procedure detected as it hears them.
- Click Generate codes. Suggested ICD-10 and CPT® codes appear with a confidence score and a plain-language explanation you can expand. Add or remove codes with the plus button; modifiers are suggested from context (telehealth, assistant-delivered, KX threshold) and can be edited.
- Link the goals addressed in the session so goal progress is recorded (see Goals and progress).
- Review the note, then Sign. A signed note is locked; changes after signing are addenda.
Detailed billing analysis
Get Detailed Billing Analysis runs a deeper pass: audit risk, payer acceptance, and compliance reasoning per code. Use it on unfamiliar payers or complex visits.
Session note history
The history panel lists prior notes for the patient so you can carry forward the plan and compare goal performance.
Sefton Voice across the practice
Hold the microphone (or turn on hands-free) and say what you need:
- Booking. “Book Maria Tuesday at three.” Fuzzy patient matching, conflict check, spoken read-back, then your yes.
- Billing. “Submit the claim for today’s visit.” It lists candidates, reads the review back, and submits when you confirm.
- Signing. “Sign the note.” A spoken attestation is recorded in the audit trail.
Privacy mode never speaks a patient’s name aloud. Voice never acts unattended: every action ends with a confirmation you give.
CPT® licence rider
The first time a practice uses CPT code suggestions, the owner accepts the CPT EULA rider by typing their full name. It is a one-time step per practice.
Frequently asked questions
Does Sefton bill anything automatically?
No. Codes are suggestions with confidence scores. Nothing is coded, billed, or signed until you confirm, and every confirmation is in the audit trail.
Which browsers support dictation?
Current Chrome, Edge, and Safari. If the browser cannot record, Quick Dictate says so and you can type the note or use the iPhone or iPad app.
Can I dictate in Spanish?
Yes. Quick Dictate and Sefton Voice work in English and Spanish.