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Chat-Based Note Template

Conversational note creation with AI prompts

An intelligent chat interface guides you through note creation with targeted questions about your session. The AI asks relevant follow-up questions and helps organize your thoughts into structured documentation.

Overview​

The guided chat assistant provides an interactive, conversational approach to creating comprehensive session notes. Through natural dialogue, the AI helps you capture all essential information while maintaining professional documentation standards.

Best for:

  • Post-session documentation
  • When you want guidance on what to include
  • Ensuring completeness of session records
  • Learning proper note structure

How It Works​

Intelligent Conversation Flow​

The AI assistant adapts its questioning based on your responses, ensuring comprehensive coverage of all session aspects while maintaining a natural, conversational tone.

Dynamic Question Generation​

Rather than following a rigid script, the assistant:

  • Responds to your input - Asks follow-up questions based on what you share
  • Identifies gaps - Prompts for missing essential information
  • Clarifies details - Seeks specificity when responses are vague
  • Maintains flow - Keeps the conversation natural and engaging

Getting Started​

Step 1: Access Chat Assistant​

  1. Navigate to your client's records page
  2. Click "Create Note" or use the "+" button
  3. Select "Chat-Based Template" from the options
  4. Choose your preferred note format (SOAP, BIRP, etc.)

Step 2: Begin the Conversation​

The AI assistant will greet you and begin with basic session information:

  • Session date and duration
  • Client presentation and mood
  • Session objectives or goals
  • General session overview

Step 3: Follow the Interactive Flow​

Respond naturally to the assistant's questions, providing as much detail as you feel is relevant. The AI will guide you through all necessary sections.

Conversation Workflow​

Initial Setup Phase​

The assistant begins with essential session details:

Opening Questions:

  • "Tell me about today's session with [Client Name]"
  • "How did the client present when they arrived?"
  • "What was the main focus or goal for today's session?"
  • "How long was the session and what was the setting?"

Session Content Exploration​

The AI dives deeper into session specifics:

Content Questions:

  • "What were the main topics discussed during the session?"
  • "Can you describe any specific interventions or techniques you used?"
  • "How did the client respond to these interventions?"
  • "What progress was observed toward their treatment goals?"
  • "Were there any significant moments or breakthroughs?"

Clinical Assessment Section​

Focused questions about clinical observations:

Assessment Questions:

  • "What behavioral observations did you make today?"
  • "Did the client report any changes since your last session?"
  • "How would you assess their mood and mental state?"
  • "Are there any risks or safety concerns to document?"
  • "What is your overall clinical impression of this session?"

Treatment Planning​

Looking forward to future sessions:

Planning Questions:

  • "What are the next steps in their treatment plan?"
  • "Are there any homework assignments or between-session tasks?"
  • "Do any treatment goals need to be modified based on today's session?"
  • "When is the next session scheduled?"
  • "Are there any referrals or additional resources needed?"

Completion and Review​

Final validation and organization:

  1. Summary review - The assistant summarizes key points from your conversation
  2. Gap identification - Asks about any missing information
  3. Clarification requests - Seeks details on unclear responses
  4. Structure generation - Organizes all information into your chosen format
  5. Final approval - Presents the draft note for your review and approval

Conversation Tips​

Effective Communication​

  • Be specific - Detailed responses generate better structured notes
  • Think aloud - Share your clinical reasoning and observations
  • Use examples - Provide specific instances when describing behaviors
  • Ask questions - The assistant can clarify what information is needed

Managing the Flow​

  • Take your time - There's no rush; thorough responses are better
  • Use "stop" command - End the conversation when you have enough information
  • Request clarification - Ask the assistant to explain any confusing questions
  • Restart option - Begin again if you want to reorganize your thoughts

Best Responses​

  • Complete thoughts - Finish your ideas before the assistant responds
  • Clinical language - Use professional terminology when appropriate
  • Context provision - Include relevant background information
  • Honest assessment - Share both positive and concerning observations

Advanced Features​

Context Awareness​

The assistant maintains awareness of:

  • Previous sessions - References past documentation for continuity
  • Treatment goals - Connects current session to established objectives
  • Client history - Incorporates relevant background information
  • Risk factors - Pays attention to safety and clinical concerns

Adaptive Questioning​

The AI modifies its approach based on:

  • Your responses - Adjusts depth and focus based on your input
  • Session type - Different questions for intake vs. follow-up sessions
  • Client population - Adapted prompts for different age groups or conditions
  • Treatment modality - Questions tailored to your therapeutic approach

Quality Assurance​

Throughout the conversation, the assistant:

  • Checks completeness - Ensures all essential areas are covered
  • Validates consistency - Flags potential contradictions
  • Suggests improvements - Recommends additional details when helpful
  • Maintains standards - Guides toward professional documentation quality

Customization Options​

Personal Preferences​

  • Question style - Choose formal vs. conversational prompts
  • Detail level - Set preferences for brief vs. comprehensive questioning
  • Focus areas - Emphasize specific aspects of documentation
  • Default formats - Set preferred note structures for different clients

Session-Specific Settings​

  • Template selection - Choose SOAP, BIRP, or custom formats
  • Length preferences - Indicate desired note comprehensiveness
  • Special considerations - Flag unique client needs or circumstances
  • Time constraints - Adjust questioning pace for available time

Quality and Compliance​

Professional Standards​

The assistant ensures notes meet:

  • Clinical guidelines - Appropriate professional language and structure
  • Documentation requirements - Complete, accurate, and timely records
  • Legal standards - Proper attribution and objective observations
  • Ethical considerations - Respectful and appropriate content

Organizational Compliance​

Integration with institutional requirements:

  • Standard formats - Compliance with organizational templates
  • Required elements - Ensures all mandatory information is captured
  • Quality metrics - Meets institutional documentation standards
  • Audit readiness - Produces documentation suitable for review

Troubleshooting​

Common Issues​

Assistant not understanding responses:

  • Rephrase your answer using different words
  • Provide more specific details or examples
  • Break complex responses into smaller parts
  • Ask the assistant to clarify what it's looking for

Questions seem irrelevant:

  • Explain your session's unique circumstances
  • Guide the assistant toward more relevant topics
  • Use the context-setting features at the beginning
  • Provide feedback about what information is most important

Conversation feels too long:

  • Use the "stop" command when you feel you've covered everything
  • Set time preferences at the beginning of the session
  • Focus on essential information first
  • Skip optional sections if time is limited

Getting Help​

  • Built-in commands - Use "help", "explain", or "clarify" during conversation
  • Session restart - Begin again if the conversation goes off track
  • Support integration - Access technical help without losing your progress
  • Feedback options - Report issues or suggest improvements

Best Practices​

Before Starting​

  • Review previous notes - Familiarize yourself with recent session history
  • Prepare key points - Have main session highlights ready to discuss
  • Set aside time - Allow 10-15 minutes for thorough conversation
  • Choose quiet environment - Minimize distractions for focused dialogue

During the Conversation​

  • Stay engaged - Treat it as a professional consultation
  • Be thorough - Include all relevant clinical information
  • Maintain focus - Keep responses relevant to the session
  • Use feedback - Let the assistant know if questions are helpful

After Completion​

  • Review the draft - Check the generated note for accuracy
  • Edit as needed - Make any necessary corrections or additions
  • Verify completeness - Ensure all important information is included
  • Approve promptly - Finalize and save the documentation

Next Steps​

Enhance your note-taking workflow:

Conversation Tip

Treat the chat assistant like a clinical supervisor who's helping you think through the session. The more you engage with the questions, the better your final documentation will be.

Last updated on by Anurag Mandal