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Clinical notes and session documentation

Automates clinical session documentation by capturing session details, generating structured notes, and updating patient records while ensuring HIPAA compliance. Reduces documentation time by 60% and improves clinical accuracy.

Workflow Trigger

Therapy session ends in SimplePractice calendar

Visual Flow

Each node represents an automated step. Connections show how data and decisions move through the workflow.

Step-by-Step Breakdown

Detailed explanation of each automated stage in the workflow.

  1. 1
    Trigger

    Session completion detected

    SimplePractice triggers when a scheduled therapy session is marked as completed. The system captures session metadata including duration, patient ID, and therapist information.

  2. 2
    Action

    Extract session voice notes

    Doxy.me integration retrieves any recorded voice notes or session summaries from the telehealth platform. Audio files are securely transferred for processing.

  3. 3
    Action

    Generate structured clinical notes

    AI processes voice recordings and session data to create standardized SOAP notes with treatment observations and recommendations. Content is formatted according to clinical documentation standards.

  4. 4
    Decision

    Review required for notes

    System evaluates if notes contain sensitive content, medication changes, or risk indicators that require therapist review before finalization. Routes accordingly based on clinical protocols.

  5. 5
    Action

    Update treatment plan progress

    TherapyNotes receives session outcomes and automatically updates patient treatment goals and progress tracking. Session data is integrated into ongoing care plans.

  6. 6
    Action

    Process insurance documentation

    Therabill automatically generates insurance claim documentation using session notes and treatment codes. Claims are prepared for submission with appropriate billing codes.

  7. 7
    Output

    Finalize documentation package

    Complete clinical record is stored in patient file with HIPAA-compliant encryption. Therapist receives notification that documentation is ready for final approval.

Outputs

  • HIPAA-compliant clinical notes
  • Updated treatment plan progress
  • Insurance claim documentation

Key Metrics

  • Documentation completion time
  • Clinical note accuracy rate
  • Insurance claim approval rate
OA

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