Approve a Note

Assign notes to clients and finalize documentation

After creating a note through recording, uploading, or using templates, the note enters a pending state where you can review, edit, and assign it to a client before final approval. This quality control step ensures accurate documentation and proper client record organization.

Why Notes Need Approval

The approval workflow serves critical functions in your practice:

• Quality Assurance - Review AI-generated content for accuracy before permanent storage
• Client Assignment - Ensure notes are properly linked to the correct client record
• Edit Opportunity - Make necessary adjustments and add clinical insights
• Compliance - Maintain professional documentation standards and accountability

Pending vs. Approved

• Pending Notes: Temporary status, fully editable, not yet in client records
• Approved Notes: Permanent documentation, locked from editing, visible in client history

Assigning a Note to a Client

Before you can approve any note, you must assign it to a client. This is a required step - you cannot approve a note without client assignment.

How to Assign a Client

1. Open the pending note from your Dashboard → Notes section
2. Locate the client assignment field (typically near the top of the note)
3. Click the edit icon next to the client email field
4. Choose one of two methods:

Method 1: Select an Existing Client

Browse through your existing client list and select the appropriate client:

• Search by name - Type the client's name to filter the list
• Browse alphabetically - Scroll through your complete client roster
• View client details - See basic information to confirm the right match
• Click to select - Client email is automatically populated

Best for:

• Returning clients
• Clients already in your system
• Sessions with known client records

Method 2: Enter Client Email Address

Type or paste the client's email address directly into the field:

• For existing clients - The system automatically links to their existing record
• For new clients - The system automatically creates a new client record using the email address

Best for:

• New clients (first session)
• Quick assignment without browsing
• When you know the client's email

Automatic Client Creation

When you enter an email address that doesn't exist in your system, Serene automatically creates a new client record. You can add additional details (name, phone, demographics) later from the client's record page.

The Critical Role of Email Addresses

Email as Unique Identifier

In Serene, email addresses are the primary unique identifier for clients. This design choice provides several important benefits:

Uniqueness Guarantee:

• Each email address can only belong to one client
• Prevents duplicate client records
• Ensures data integrity across your practice
• Maintains accurate session history

Cross-Platform Consistency:

• Email remains constant even if name or phone changes
• Links sessions across different services
• Maintains continuity in client records
• Enables secure client portal access

Communication Foundation:

• Primary contact method for notifications
• Portal access and appointment reminders
• Intake form delivery
• Session confirmations

Why Email Accuracy Matters

Using the correct email address is critical for several reasons:

1. Proper Record Association

   • Notes must link to the correct client history
   • Treatment plans and progress tracking depend on accurate assignment
   • Analytics and insights aggregate by unique client

2. Client Portal Access

   • Clients use email to access their secure portal
   • Intake forms are delivered via email
   • Appointment confirmations and reminders are sent to this address

3. Data Integrity

   • Once approved, notes are permanently associated with the email
   • Changing email later requires creating a new client record
   • Session history must remain accurate for legal and clinical purposes

4. Team Coordination

   • In team practices, email ensures everyone accesses the same client record
   • Shared notes and treatment plans rely on consistent client identification
   • Communication and handoffs depend on accurate client matching

Verify Email Before Approval

Always double-check the email address before approving a note. Once approved, the note is permanently linked to that email address. If you need to change the client assignment after approval, you must unapprove the note first.

Handling Email-Related Scenarios

Client doesn't have email:

• Use a practice-managed email (e.g., client-name@yourpractice.com)
• Document the situation in client notes
• Update to client's real email when available

Client wants to change email:

• Update the email in their client record settings
• New sessions will use the updated email
• Previous session history remains linked to the new email
• Portal access updates automatically

Duplicate clients with different emails:

• Contact support for record merging if the same person has multiple records
• Choose one primary email for future sessions
• Document which email is active in client notes

Team member enters wrong email:

• Unapprove the note before making changes
• Update the client email assignment
• Re-approve once corrected
• Previous versions are not retained after approval

The Approval Process

Once you've assigned a note to a client and reviewed the content, you're ready to approve it.

Steps to Approve

1. Review the note content thoroughly:

   • Check AI-generated summary and insights
   • Verify all structured sections (SOAP, BIRP, etc.)
   • Ensure clinical accuracy and completeness
   • Add any missing observations or context

2. Confirm client assignment:

   • Verify the email address is correct
   • Ensure it matches the actual client from the session
   • Check that client details are accurate

3. Check the "Approved" checkbox:

   • Located at the top of the note interface
   • Click to mark the note as approved
   • Confirm any approval dialogs that appear

4. Automatic finalization:

   • Note immediately moves from pending to approved status
   • Content becomes locked and read-only
   • Note appears in client's permanent record
   • Analytics and treatment tracking are updated

What Happens When You Approve

• The note is permanently added to the client's record
• All sections become read-only and cannot be edited
• The note appears in client history chronologically
• Progress tracking and analytics incorporate the new data
• Team members with shared access can view the note

Editing After Approval

If you need to make changes to an approved note:

Unapproving a Note

1. Uncheck the "Approved" checkbox at the top of the note
2. Note reverts to pending status immediately
3. All editing capabilities are restored
4. Note temporarily disappears from client's permanent record
5. Make your edits as needed
6. Re-approve when changes are complete

Temporary Removal

When you unapprove a note, it is temporarily removed from the client's record until you approve it again. This maintains data integrity and ensures incomplete edits don't appear in clinical documentation.

What You Can Edit in Pending Status

While a note is pending (or unapproved):

• Session summary and conversation highlights
• Structured sections (Subjective, Objective, Assessment, Plan)
• Topics and themes identified by AI
• Client assignment and email address
• Session metadata (date, duration, session type)
• Clinical observations and personal insights
• Privacy settings and sharing options

What Is Locked in Approved Status

Once a note is approved, these elements become read-only:

• All content sections and text
• Client assignment and email
• Session metadata
• Topics and categorization
• Timestamps and version history

Best Practices

Before Approval

✅ Verify client email carefully - This is your most important step ✅ Review AI-generated content - Check for accuracy and completeness ✅ Add clinical insights - Include observations AI may have missed ✅ Check for sensitive information - Ensure appropriate privacy handling ✅ Confirm session details - Verify date, duration, and type are correct

Email Management

✅ Use consistent email format - Maintain standardized email entry ✅ Create a verification checklist - Build email verification into your workflow ✅ Document special cases - Note when using practice-managed emails ✅ Update promptly - Change client emails when notified ✅ Train team members - Ensure everyone understands email importance

Workflow Efficiency

✅ Approve within 24 hours - Review notes while session is fresh ✅ Batch similar reviews - Process multiple notes in dedicated time blocks ✅ Set quality standards - Establish consistent documentation criteria ✅ Use mobile access - Review and approve between sessions if needed ✅ Monitor pending count - Keep backlog manageable

Troubleshooting

Cannot Approve Note

Problem: Approval checkbox is disabled or clicking has no effect

Solutions:

• Verify client email is assigned (required field)
• Check that all required sections are completed
• Ensure you have editing permissions for this note
• Refresh the page and try again
• Contact support if issue persists

Wrong Client Assigned After Approval

Problem: Note was approved with incorrect client email

Solutions:

1. Uncheck the "Approved" checkbox to revert to pending
2. Click edit on the client email field
3. Enter or select the correct client email
4. Verify the email is accurate this time
5. Re-approve the note with correct assignment

Client Email Doesn't Exist

Problem: Entering email for new client but want to add more details first

Solutions:

• Enter the email anyway - client record is automatically created
• Approve the note with just the email
• Navigate to Clients section to add full details later
• Use the client's record page to add name, phone, demographics

Duplicate Clients Created

Problem: Same client has multiple records with different emails

Solutions:

• Choose one primary email for future sessions
• Document which email is active in both client records
• Contact support for help merging duplicate records
• Update your workflow to prevent future duplicates

Note Disappeared After Unapproving

Problem: Can't find note after unchecking approval

Solutions:

• This is normal behavior - note is in pending status
• Access from Dashboard → Notes section
• Look under Pending Notes, not in client record
• Note will reappear in client record once re-approved

Next Steps

Once you understand the approval process:

• Learn about Pending Notes management → - Comprehensive pending workflow
• Explore session recording → - Create notes from live sessions
• Understand client records → - How approved notes integrate

Pro Tip

Create a pre-approval checklist that includes email verification, content review, and quality checks. This ensures consistent documentation standards and prevents common approval mistakes. Most practitioners find that this small investment in process saves significant time correcting errors later.