AI Charting
AI charting in medical health software helps clinicians create and complete client chart notes faster by turning audio inputs into template documentation during either in person or telehealth sessions.
It can generate & suggest content, pull relevant history, and reduce repetitive typing. Under further edits (explained), AI can help generate clear, organized clinical notes that align with common therapeutic and psychiatric documentation requirements.
It saves time by drafting notes, catching missing details, and streamlining workflows so providers mostly review and finalize instead of writing from scratch. This frees up more time for you, including for client care and can improve documentation quality.
Pros:
- Cuts documentation time, enabling more potential patient visits and revenue.
- Automates charting, saving clinicians hours weekly.
- Decreases admin and overtime costs
- Reduces clinician burnout
- Produces complete charts in minutes
- Lowers administrative overhead
- Standardizes notes for compliance, including for various insurances
Summarized steps:
We will break this down in more detail, giving examples and even edit prompt ideas to help. Think of this as a funnel as we slowly form your chart the way you need it, here we realize everyone's needs are different!
The steps below show in order from left to right the 3 main steps in charting with AI.
AI charting will do the hard work, transcribing and then summarizing a chart note based on both the interaction + the template you've chosen.
Once a rough draft is generated, make unlimited free edits to your note using natural language commands we discuss further down in the editing process.
Once you insert the note into our charting, there you can further review and make smaller edits as needed. Then lock your note and you're done!
Your responsibility & ethical standards:
The fun stuff:You are solely responsible for reviewing and validating any AI-generated outputs. We make no representations or warranties regarding the accuracy, completeness, or suitability of AI-generated responses for your specific needs. AI-generated content should not be used as a substitute for professional judgment, including but not limited to billing, coding, claims processing, or medical decision-making.
In this Article:
- Overview: How AI charting works
- Enable or disable AI notes
- How to chart:
- Hang ups
- AI Charting Usage Report
Overview: How AI charting works
AI charting has if you can think of it this way multiple steps in a funnel filter_alt process and 'carves down' your chart note to further refine it. We've created a visual and will go in depth more below:
Most of this step is done for you!
Here's the process:
- You're presented with a generalized template AI has created based on your session
- This inputs relevant information based on prior AI training of sessions inline with the chart note templates
- In this second stage you can further add general writing renovation edits to further customize in our second filter step explained in the next panel (right):
Free edits! With the chart note generated, you may wish to make unlimited free edits, re-generate as many times as you need via natural language input.
Example edit prompts:
- Make this note more concise
- Include more session quotes
- Make symptoms more specific for X
- Improve the treatment plan section for ...
- Make this note ready for insurance review in specific topics X Y Z
- Have an edit prompt that would be helpful to others? Email us!
The last filter step: YOU!
- Here your AI generated chart note + your edits are inserted into our system automagically.✨
- Review it carefully, making any granular edits and proceed.
This is an extremely important last step. This is last time to review your chart note before you finalize it.
Next steps:
- Once you've carefully reviewed your chart note, click (bottom right)
- On the next screen, permanently lock your chart note by clicking the bottom right button
Keep in mind AI is not perfect and trusting it blindly has resulted in several legal hang ups. For example, some include lawyers that submitted court paperwork with hallucinated fake court cases cited. Or more recently a police officer that stated on an official report they were magically turned into a frog. 🐸
The tech industry calls this a hallucination
We say be careful! You own the note. Always verify accuracy before you lock it.
Enable or disable AI note
To disable or enable AI notes, from any page:
- Click (top right)
- Then click Staff (top tab)
- Click on the provider you want to enable or disable AI notes for
- Scroll and find the section titled Roles
- Under the Therapist role find the AI Charting sub role and click shown below:
Want to disable AI charting?
Following the same steps above. The button will show a button you'd click instead.How to chart
Important: The AI charting button will only appear with two different chart note types:
- The Progress Note (HIPAA)
- The Narrative Note (Simple)
The SOAP Note template will remain unchanged.
Acceptable chart types:
You can still use AI charting to generate a SOAP note, that is one of the template options to choose from. You just initially have to chose one of the above two note types initially.
Charting depends on which method you decide to use. We have steps for all 4 options here:
In person
Access your chart note as you normally would:
- From the click on the appointment
- Click the top right button
- Scroll down to the Notes section & on the right click shown below:
- Next you'll see this audio input option, allowing you to pick from any available system microphones:
- Please ensure you see the microphone respond
- If you don't see any input, use the dropdown to change source to the microphone you prefer to use:
- On the next screen, keep the option In-Person selected and click
- Once you click this, the session will immediately begin.
- Click to either pause or end the session
- We will then begin automatically generating your chart note based on your chart type selection, and the transcription recorded.
- Please don't navigate away or close this window, or your progress will be lost.
- To be clear, this is not a transcription service. AI charting compiles a chart note based on all the audio/transcribed input
Even after generation, you can still change your templates:
- SOAP
- DAP
- BIRP
- GRIP
- SIRP
- PIRP
- PIE
- PIRP
- PIE
- Intake
- Case Management
- Supervision
- Headway SOAP
- Headway Intake
- Pick your note type
- Click
- Make further edits below
After clicking, a new pop up will show up. We're generating your note within it. Please don't navigate away or close this window, or your progress will be lost.
Once generated you should see something similar to this:
Here you have a few options that we'll break down:
Chart note type
At the top right you can switch between chart note type you prefer shown above. The default is SOAP.
At the bottom right we have the following options:
Edit ( free! )
Enter your details in the bottom center text box, then click to the right to regenerate the note. Editing is free of charge.
Example edit prompts:
- Make this note more concise
- Include more session quotes
- Make symptoms more specific for X
- Add _ and supporting details to the treatment plan section
- Make this note ready for insurance review in specific topics X Y Z
- Have an edit prompt that would be helpful to others? Email us!
Replace notes
After thorough review and satisfied with the generated note, click (bottom right). This will add the note and overwrite any other note you have entered in this section.
Don't worry, if you need to make changes after the fact, you still can do so in the notes section of your generated chart note inserted, but you won't be able to use the edit box specifically to regenerate.
Add to notes:
If you already have existing notes, and would just like to append this output to it, click instead (bottom right).
Discard
Clicking that will discard any note generated. You will still be charged for this generated note.
Once added to notes:
Your generated note will be added to the notes section of the notes. You should see something similar to this:
Want to create a treatment plan as well?
- Review your chart note and ensure it's correct, then scroll down and click (bottom right)
- On the next page check off Create/Include Treatment Plan at the bottom right above before clicking it.
- For more details, review our article here: Treatment Plans
Built in telehealth
Steps:
- The quickest way to initiate this is to join the telehealth session and just record from there
- We will then automatically generate an AI chart note for you to review
Interactive steps:
Overall steps
Begin the telehealth session.
Once joined, click Record (bottom right). On a smaller screen click More ... first.
When done end the session and go to your chart note for this appointment.
After recording and ending a session, the AI will automatically generate a chart note draft for you. It allows you to:
- Pick the template you want your note generated in
- Make unlimited free refined edits and then insert the chart note into our editor.
Once the AI has done the heavy lifting and the chart note is in our editor.
Carefully review the chart note for accuracy, then make granular edits or add/remove wherever you need.
Join telehealth and record:
- Within 15 minutes of the appointment, go to your dashboard or calendar and click on the appointment
- Clients can also join within the same time frame from their dashboard
- In the pop up click (top right)
- Then click again
- Continue with the prompts, allowing any audio and video permissions that are need by you & your provider.
- Once you join the telehealth session, click the bottom button Record shown here:
- We really only need the audio/transcript, but you're welcome to record video as well for yourself and reviewing back
- Once recording starts, begin your session as you normally would and quit telehealth when finished
Charting
- We will then begin automatically generating your chart note based on your chart type selection, and the transcription recorded.
- Please don't navigate away or close this window, or your progress will be lost.
- To be clear, this is not a transcription service. AI charting compiles a chart note based on all the audio/transcribed input
Even after generation, you can still change your templates:
- SOAP
- DAP
- BIRP
- GRIP
- SIRP
- PIRP
- PIE
- PIRP
- PIE
- Intake
- Case Management
- Supervision
- Headway SOAP
- Headway Intake
- Pick your note type
- Click
- Make further edits below
After clicking, a new pop up will show up. We're generating your note within it. Please don't navigate away or close this tab, or your progress will be lost.
Once generated you should see something similar to this:
Here you have a few options that we'll break down:
Chart note type
At the top right you can switch between chart note type you prefer shown above. The default is SOAP.
At the bottom right we have the following options:
Edit ( free! )
Enter your details in the bottom center text box, then click to the right to regenerate the note. Editing is free of charge.
Example edit prompts:
- Make this note more concise
- Include more session quotes
- Make symptoms more specific for X
- Add _ and supporting details to the treatment plan section
- Make this note ready for insurance review in specific topics X Y Z
- Have an edit prompt that would be helpful to others? Email us!
Replace notes
After thorough review and satisfied with the generated note, click (bottom right). This will add the note and overwrite any other note you have entered in this section.
Don't worry, if you need to make changes after the fact, you still can do so in the notes section of your generated chart note inserted, but you won't be able to use the edit box specifically to regenerate.
Add to notes:
If you already have existing notes, and would just like to append this output to it, click instead (bottom right).
Discard
Clicking that will discard any note generated. You will still be charged for this generated note.
Once added to notes:
Your generated note will be added to the notes section of the notes. You should see something similar to this:
Want to create a treatment plan as well?
- Review your chart note and ensure it's correct, then scroll down and click (bottom right)
- On the next page check off Create/Include Treatment Plan at the bottom right above before clicking it.
- For more details, review our article here: Treatment Plans
Zoom (telehealth)
If you're using our Zoom telehealth option use these steps to generate an AI note with your session.
Your steps:
Begin the session first, which opens a new tab for telehealth. Return back to the previous tab and go to the calendar. Open the appointment and click on charting. Open the AI charting button and select your configuration as telehealth then your headphone configuration. Lastly, be sure to share the zoom audio with our tab and that's it. Just be sure you hit record.
After recording and ending a session, the AI will automatically generate a chart note draft for you based on your template slected for you to further edit and finalize.
Once the AI has done the heavy lifting and is inserted into our charting screen, you can further review and make smaller edits as needed as you normally would.
Interactive steps:
Using Headphones?
If so, there are some rather specific instructions in order to get those to work based on browser.
Our AI partner has expressed recommending Chrome instead of Safari as Chrome is the only supported browser to record sessions when using headphones.
Once you select headphones you're prompted at the top center of which tab (or app/window) you'd prefer to share.
- Select Window on the right
- Click Zoom
- Ensure sound is also shared:
Our AI partner has expressed recommending Chrome instead of Firefox as Chrome is the only supported browser to record sessions when using headphones.
Steps:
- Within 15 minutes of the appointment, go to your dashboard or calendar and click on the appointment
- Clients can also join within the same time frame from their dashboard
- In the pop up click Start Session (top right)
- Then click again
Before you begin...
Lastly, we just need to bring up the chart note and begin the AI chart note recording. Once you join the telehealth session:
- From the (left menu) click on the appointment
- Click (right menu)
- Scroll down to the Notes section & on the right click shown below:
- Select Telehealth in the dropdown
- You'll then be prompted to allow your microphone and camera, click Allow & continue
- Test and choose your microphone (not speakers/output)
- You'll see a live mic indicator below the drop down
- Click Next
- Select Telehealth
- In the dropdown below it select whether you're using Headphones or not
- If you're not using headphones, click Start Recording — recording will immediately begin
- If you're using headphones, in order to hear your system audio you'll need to share your tab with the telehealth session on another prompt
- When the screen picker appears, select your telehealth session
- Enable the 'Share audio' option at the bottom before clicking Share
- Select Allow then Start Recording
- Return back to your telehealth tab and perform your session
- If you need to pause, click Stop Recording
- When complete, click Stop Recording, then End Session
- We will then begin automatically generating your chart note based on your chart type selection, and the transcription recorded.
- Please don't navigate away or close this window, or your progress will be lost.
- To be clear, this is not a transcription service. AI charting compiles a chart note based on all the audio/transcribed input
Even after generation, you can still change your templates:
- SOAP
- DAP
- BIRP
- GRIP
- SIRP
- PIRP
- PIE
- PIRP
- PIE
- Intake
- Case Management
- Supervision
- Headway SOAP
- Headway Intake
- Pick your note type
- Click
- Make further edits below
After clicking, a new pop up will show up. We're generating your note within it. Please don't navigate away or close this window, or your progress will be lost.
Once generated you should see something similar to this:
Here you have five options that we'll break down:
Chart note type
At the top right you can switch between chart note type you prefer shown above. The default is SOAP, and each other template is listed above.
At the bottom right we have the following options:
Edit ( free! )
Enter your details in the bottom center text box, then click to the right to regenerate the note. Editing is free of charge.
Example edit prompts:
- Make this note more concise
- Include more session quotes
- Make symptoms more specific for X
- Add _ and supporting details to the treatment plan section
- Make this note ready for insurance review in specific topics X Y Z
- Have an edit prompt that would be helpful to others? Email us!
Replace notes
After thorough review and satisfied with the generated note, click (bottom right). This will add the note and overwrite anything you've already entered in this section.
Don't worry, if you need to make changes after the fact, you still can do so in the notes section of your generated chart note inserted, but you won't be able to use the edit box specifically to regenerate unless you re-enter the AI notes editor.
Add to notes:
If you already have existing notes, and would just like to append this output to it, click instead (bottom right).
Discard
Clicking that will discard any note generated. You will still be charged for this generated note.
Once added to notes:
Your generated note will be added to the notes section of the notes. You should see something similar to this:
Want to create a treatment plan as well?
- Review your chart note and ensure it's correct, then scroll down and click (bottom right)
- On the next page check off Create/Include Treatment Plan at the bottom right above before clicking it.
- For more details, review our article here: Treatment Plans
Outside telehealth solutions
If you're not using one of our integrated solutions, essentially you'll just need to make sure our AI tool is listening to both of your voices.
Essential steps:
In our system, open the appointment and click on charting. Open the AI charting button and select your configuration. Then click record. Then open your telehealth program
After recording and ending a session, the AI will automatically generate a chart note draft for you based on your template slected for you to further edit and finalize.
Once the AI has done the heavy lifting and is inserted into our charting screen, you can further review and make smaller edits as needed as you normally would.
You can use our in person option if your microphone can also hear their voice (like with speakers), or select the Telehealth option to record your telehealth system's audio so AI charting can hear it.
Our recommendation would be to use one of our two integrated telehealth solutions. For more information about these two options please see below:
- Zoom telehealth (requires Zoom license)
- Integrated telehealth
Hang ups
In extremely long sessions, or if you have unexpected network connectivity issues, you may return to the charting screen and see two options
- Here you'll see a screen with a similar hang up
- On the right, note the two buttons instead of the start / stop recording options:
Causes and solutions:
Here are the leading causes of this:
- Timeout and possible sign out of the system while charting due to inactivity consistent with your security settings
- Internet connection issues
- If you've already generated and inserted the AI chart note
In this instance you have two options:
Clicking brings you back to the current AI chart note progress you've been working on. If needed, you can use the feature and refine the chart note as many times as you need for free.
Clicking creates a brand new chart note, resetting all your progress currently.
This restarts the process entirely.
AI Charting Usage Report
With our reporting, you're able to see an in depth view of you or your groups use of the AI charting feature. Filterable and easily readable.
- Reporting: AI Charting Usage