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Notes, signing & the sign queue

A note isn't done until it's signed — the signature is what turns a draft into part of the legal record. This page covers where notes live, how signing and unlocking work, and how to keep the queue at zero.

In this guide, we'll cover:

Where notes live​

  • On the client's chart — the Dashboard tab is the per-client view. Each appointment in the chart history has an Add Progress Note button that opens a note on that session, next to Dictate and Live Session. The Add a note... bar at the top is for chart notes (a call, an email, a comment); when a session from the last week has no note yet, its buttons first ask Which appointment is this for?. See Where a note starts.
  • Notes to Sign (left sidebar) — your cross-client queue at a glance: your own notes needing attention, unsigned treatment plans, and treatment plans due for review (the sidebar count adds notes and plans due for review). If you supervise others, your co-sign queue lives on the Supervision dashboard, not here.

Working the queue​

The Notes to Sign page with status filters

The Notes to Sign page ("Notes and treatment plans that need your attention") is built for the end-of-day sweep:

  1. The default filter, Needs signature, is your to-do list; under supervision you also get Submitted (with your supervisor) and Returned (sent back for edits).
  2. The Waiting column counts days since the session — anything older than two days turns red (or orange while it's your supervisor's move), so the oldest debts stand out.
  3. Click a row to open the note, sign it, and come back — "You're all caught up" is the goal state.

Above the table, a Treatment plans to sign section appears when any client has an unsigned treatment plan — each row opens the plan so you can sign it there. A Plans due for review section appears when any treatment plan is approaching its review date, badged Overdue or Due soon.

Where a note starts​

A session note belongs on its appointment. That is what the missing-notes count, the chart timeline and billing all look at, so start it from the session:

  • On the client's chart, scroll to the appointment and click Add Progress Note. It opens a note on that session in your default template; click the note's title to change the template while it is still blank. Dictate and Live Session sit beside it and land on the session too.
  • On the calendar, click the appointment and choose Type Note, Dictate or Record.
  • From the Add a note... bar at the top of the chart: if a session from the last week has no note yet, Type, Dictate and Live Session first ask Which appointment is this for? Pick the session and the note lands on it (Type opens your template there); pick Not for an appointment for an independent chart note.

On a fresh, still-empty typed note, click the note's title to change its template.

The box at the top of the chart is for chart notes, not session notes (below).

Quick chart notes​

Not every entry is a session note. Click Type in the Add a note... bar on the client's Dashboard (if a recent session has no note it first asks which appointment; choose Not for an appointment) to open Add Chart Note, a free-text box for a phone call, an email, a records request, or collateral contact. It has its own date and time (defaults to now). Click Save chart note and it files onto the chart as a draft like any other note. A chart note belongs to the client, not to a session.

The box can also start a document that is not about one session, such as an intake summary or a discharge note:

  • Type into a template instead (top right of the box) opens the full note editor with that template's sections ready to fill in.
  • Generate with AI (once you've typed at least 15 words) picks a template and the AI structures what you typed into it.

If the client had a session in the last week with no note yet, choosing a template here asks whether you meant that session. Go to the session opens the template on it; No, this is a separate document carries on as a document not tied to any session. Nothing is attached to a session unless you choose it. To dictate something that is not about a session, use + New → Dictate on the chart.

Editing a note​

Open any unsigned note to work on it:

  • Edit sections directly; changes are held locally until you click Save — there's no autosave, and closing the browser with unsaved edits warns you first.
  • The wand icon on each section is Magic Edit — AI refinement of just that section.
  • Load last note (top of the note) copies the client's previous note into this one, section by section — form sections take the earlier answers, text sections the earlier text — so you edit what changed instead of starting over. The arrow beside it lists the client's last 25 notes to pick an earlier one. Nothing is saved until you click Save. When the previous note is laid out differently (another template, or a note imported from another system), you are offered Use its layout: this note takes the previous note's sections and content, keeping today's date and appointment, and that change is saved at once. Fill matching copies only the sections both notes share. Refit into this note keeps this note's template and has the AI fill its sections from the previous note's text, copying rather than rewriting: form answers are ticked from what the text says, and narrative passes through word for word. The text stays on the note as Text before refit.
  • Prefill last on a form section does the same for that one section.
  • Refit into template... (⋮ menu) does the same for a note that holds text but no transcript, such as a note imported from another system or one you typed freely: pick the template, and its sections are filled from the note's own text, which is kept as Text before refit.
  • Regenerate Note... (⋮ menu) re-drafts the whole note from the session transcript (or the text before refit) with a different template — available while unsigned, for notes that have one.
  • Record more... (⋮ menu, same notes) records or dictates an addition of up to 15 minutes. The new audio is added to the end of the transcript and the note is regenerated from the whole thing, which replaces any edits you made to the note text.
  • The ⋮ menu also offers Copy all sections (the whole note as text, to paste elsewhere), Print, Download PDF, and — for unsigned notes only — Delete Note (which removes the note and its transcripts, permanently).

Signing​

Click Sign Note at the top of the note when it's ready.

The top of an unsigned note with Sign Note and the ⋮ menu

Signing:

  • Stamps the note with your name, credential, license, and timestamp — shown in the signature block and on the PDF.
  • Locks the clinical content — sections become read-only, Magic Edit disables, and the note badge flips to Signed. The note keeps its original session date; signing later never moves it.

Correcting a signed note​

Signed doesn't mean untouchable — it means accountable. Unlock Note (on any signed note) reverts it to draft for editing, with guardrails:

  1. Pick a reason — Correction / Error Fix, Add Missing Information, Change Note Template, Supervisor Requested Changes, Late Entry / Addendum, or Other.
  2. The unlock is recorded in the audit trail, and the note itself displays the provenance — "Unlocked by [name] on [date] — [reason]."
  3. Edit, then sign again.

There's no separate addendum document type — late additions are made by unlocking with the "Late Entry / Addendum" reason, so the correction history stays attached to the note itself.

Under supervision​

For supervised clinicians the flow adds one round-trip:

  1. Your sign button reads Submit for Review — the note shows Awaiting Supervisor Review and moves to your Submitted filter.
  2. Your supervisor either Co-Signs (note finalizes with both signatures — Provider and Supervisor cards in the signature block) or clicks Request Edits with a comment.
  3. Returned notes appear under your Returned filter with the supervisor's comment shown on the note — revise and resubmit.

See Supervision for the supervisor's side.

Keeping documentation current​

  1. Record or dictate close to the session while it's fresh (see Recording a Session).
  2. Sweep Notes to Sign to zero on a regular rhythm — the Waiting column keeps you honest.
  3. Check the Notes Report monthly: it matches sessions to notes and flags the one thing the queue can't — a session with no note at all ("Missing note").

Troubleshooting & FAQ​

I typed a note on the chart and it isn't attached to the session. A note typed from the Type button on the chart is a standalone chart note — it's for things not tied to an appointment (phone calls, records requests, collateral contact), and it can't be moved onto one. For a session note, start from the appointment itself: on the chart timeline or the calendar, open the appointment and use its note box or Type action there. If you've already typed the content on the chart, copy it (the Copy Text button), create the note from the appointment, paste, and delete the chart note.