Progress Notes AI™-AI-powered Progress Notes Assistant

Example

Using the SOAP format, the AI guides therapists to document the subjective, objective, assessment, and plan sections thoroughly. For instance, it ensures that a therapist includes detailed observations of a client's mood and affect, such as 'client appeared anxious and had a blunted affect.'

Scenario

In a therapy session focusing on anxiety management, the AI prompts the therapist to note not only the client's self-reported anxiety but also observable behaviors and the therapist's professional assessment. This results in a more comprehensive and clinically useful progress note.

Example

The AI prompts the inclusion of specific details like the need for continued treatment due to active symptoms, such as 'client continues to experience depressive symptoms affecting daily functioning,' which is critical for justifying the ongoing therapy sessions.

Scenario

During an insurance review, the therapist’s notes need to clearly demonstrate the necessity of continued sessions. The AI ensures that all necessary elements are documented to avoid potential reimbursement issues.

Example

The AI helps document whether the current treatment plan goals are being met, need adjustment, or if new goals should be added. For instance, 'continue with current treatment goals focusing on reducing anxiety through cognitive restructuring.'

Scenario

As a client's condition improves or deteriorates, the therapist is guided to update the treatment plan in the notes, ensuring that the therapy remains aligned with the client's needs and that progress is clearly documented.