Documentation and notes
Session notes, SOAP, and evaluations
Write or dictate SOAP notes, save drafts, sign, add addenda, and produce comprehensive, focused, and re-evaluation reports as PDFs that go to the billing queue.
Every visit gets one note. You can dictate it (Quick Dictate) or write it here.
SOAP
The note has four fields, Subjective, Objective, Assessment, and Plan. Templates from your library prefill structure for evaluations, treatment sessions, and parent training. Save as draft while you work; the Sessions view keeps flagging the visit until the note is signed.
Signing
Sign records your attestation, the time, and your credentials. Assistants’ notes go to the supervisor’s queue (Supervisor co-sign). Sign by voice with a spoken attestation if you prefer.
Evaluations
Choose the type: Comprehensive Evaluation, Focused Evaluation, Re-evaluation, or Resubmit for Continued Services (which links the previous evaluation). Generate Evaluation PDF builds the report from the appointment and transcription data; preview it; then either download it or Submit to Payer. Electronic submission goes through the clearinghouse; Manual gives you the PDF to send yourself. Track it on the evaluation submissions page.
From note to billing
Submit to billing queue moves the signed note into Billing, where the claim or superbill is created. Batch Claim Generation creates CMS-1500s for every signed note that does not have a claim yet. See Superbills and CMS-1500.
Sharing with families
Signed notes you mark as shared appear in the portal’s Session Notes tab in a calmer, plain-language format and in the family’s language.
Frequently asked questions
Can I edit a signed note?
A signed note is locked. Add an addendum; it is dated, attributed, and shown with the original.
What is the difference between a draft and a signed note?
A draft is yours to change and is not billable. Signing locks the note, stamps your attestation, and makes the visit eligible for a claim or superbill.