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Notes is where a solo or team practice does all of its clinical documentation. You write about a client, save it as a draft while you think, then sign it — and signing is what turns it into a record.

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What you’re looking at

The left rail is headed Clinical Notes and holds New Note, Templates, Custom Templates and Snippets, with an AI heading below them over a single entry, AI Notes. That last one opens a panel over whatever you are doing rather than navigating away. New Note opens a page headed New Progress Note — “Create a new clinical note or documentation entry” — offering three ways in: Below those: a Waiting on you ({n}) card, shown only when something is pending your countersignature; the Quick Note card you write in; and Recent Notes, a searchable list badged Locked, Draft or Final with a View button on each row. A brand-new practice sees “No recent notes found. Create your first note above.” and no Waiting on you card at all.

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Write a quick note

1

Name it and pick a shape

Enter a Note Title (“Enter note title…”), then a Template Type: SOAP Note, Progress Note, Initial Assessment, Therapy Session, Discharge Summary, Treatment Plan or General Note.
2

Attach it to a client

Open the Client picker (“Search for a client…”) and search by name, client ID or national ID. If they are not registered, Register new client takes you there without losing what you have typed.A draft saves without a client. A final note does not — you are stopped with “Please select a client before saving the final note”.
3

Tag it and write

Tags (“Add a tag…”) make the note findable later. Write the body in Note Content. The placeholder tells you the shortcut that matters: “Start typing your note content… Type / for snippets”.
4

Save as a draft, or sign it

Save as Draft keeps it editable. Sign & Lock finishes it. Upload File attaches supporting material, and Clear empties the card.

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Sign and lock

Select Sign & Lock to open the Sign & Lock Note sheet — “Once signed, this note becomes read-only”. Check the Signing Provider, then add the Provider Signature: Typed, which previews under the heading Electronic Signature, or Draw, which needs a real signature drawn in the box before it will accept. Below that is an attestation you must tick — it confirms you have reviewed the note, that locking it prevents further changes, and that “This electronic signature has the same legal effect as a handwritten signature.” Then select Sign & Lock. You will see “Note Signed & Locked”. A locked note carries a Read-Only (Locked) badge and reads “This note is locked and cannot be edited” where its buttons used to be. Both of those are selectable — they reopen the sheet in unlock mode, where you confirm and select Unlock Note. The note becomes editable again and must be re-signed.

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Countersign a colleague’s note

Waiting on you ({n}) collects work by somebody you supervise: “Notes signed by a colleague you supervise. They are not final until you countersign.” Select Read the note, read it properly, then countersign from the panel underneath.

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The AI writing tools

Two live in the editor toolbar and work on text you have already written:
  • AI Rewrite improves a passage — “Content has been enhanced. Review before saving.”
  • AI Autocomplete suggests the next few words in grey as you type. Its tooltip reads “AI Autocomplete (on) — Tab to accept”. Press Tab to take it, Escape to dismiss it.
Both need the Essential plan. To draft a whole note from a recording instead, use the AI Note Taker — a separate add-on, not a plan feature.
AI text is a first draft, never a record. Read every sentence before you sign — your signature makes the words yours.

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Who can do this

Role decides whether Notes opens. Permission decides what you may do once it is open. Two behaviours surprise people:
  • Enforcement is opt-in, per person. A colleague never saved in the permissions sheet is unrestricted. The sheet warns “Saving starts enforcing”.
  • A denied action is recorded; an allowed one is not. Hiding Notes from somebody’s sidebar is a convenience, not a security boundary.
See Staff permissions.

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Check it worked

The note is in Recent Notes with the right client against it and a Final or Locked badge, and it is on that client’s chart. A signed note names the signing provider and cannot be edited until it is unlocked.

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Common issues

A final note must belong to somebody. Choose them in the Client picker — or, if they are not registered yet, use Register new client in the picker itself. See Clients.
Signing and locking need the Starter plan or above: “The ability to electronically sign and lock clinical notes is a premium compliance feature.” On Free you can write and save drafts. See Change your plan.
The Free plan caps how many notes you can write each month. The count resets at the start of the next month; paid plans remove the cap.
No client is selected. The button stays disabled until one is.
Both need the Essential plan — the tooltip reads “Upgrade to use AI Rewrite”. They are separate from the AI Note Taker, which is an add-on bought per person.
Select the Read-Only (Locked) badge, confirm, and select Unlock Note. Unlocking removes the signature, so re-sign after editing. Both the lock and the unlock are in your audit log — amend rather than working around it.

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FAQ

Not while it is locked. Unlock it, edit, and sign again. The original signature is removed by unlocking, and both events are recorded, so the history of the correction is preserved.
A draft is visible to your practice as a draft, and can exist without a client attached at all. Only a saved final note reads as documentation of the encounter.
Template Type is a label on a quick note. A template is a whole structured form with its own sections — see Note templates.
Type / in the note body and pick it from the menu. The Snippets page’s own buttons copy to the clipboard instead — see Snippets.
Yes — telehealth has its own notes panel beside the call. See Run a video session.