Generate Your Note
Multiple ways to create session documentation
Serene gives you several ways to produce session notes — from fully manual to fully automated. Pick the method that fits your workflow.
Methods at a Glance
| Method | How it works | Best for |
|---|---|---|
| Create A Note | Write manually, use AI chat prompts, or dictate by voice | Post-session documentation when you don't have a recording |
| Session Scribe | Records your screen + mic during a live session, then generates a note automatically | Online sessions where you want hands-free documentation |
| Upload Session | Upload a pre-recorded audio or video file for automatic transcription and note generation | Sessions recorded on Zoom, Teams, or a voice recorder |
| Upload Note | Upload images of handwritten notes or a PDF | Digitizing paper notes or importing from another system |
All methods except Upload Note produce a structured note that enters your Pending Notes queue for review before it's added to a client's record.
Note Formats
Every note in Serene uses one of three formats. You can switch between them at any time from the note editor.
SOAP
| Section | What to include |
|---|---|
| Subjective | What the client reported — thoughts, feelings, concerns |
| Objective | Your observations — behavior, appearance, mood, affect |
| Assessment | Your clinical impression based on the session |
| Plan | Next steps — goals, referrals, interventions, homework |
BIRP
| Section | What to include |
|---|---|
| Behavior | Client's actions, expressions, demeanor |
| Intervention | Strategies or techniques you used |
| Response | How the client reacted to the interventions |
| Plan | Follow-up goals or actions for future sessions |
Unstructured
A rich text editor with formatting tools (headings, bold, italic, lists, links). Write in whatever style you prefer. Content is stored as markdown.
What's in a Note
When you open a note in the editor, you'll see these sections:
Header — Client name and email, session date/time, approval status, importance flag
Summary — A short overview of the session (auto-generated for AI notes, or written by you)
Session Analytics — Duration chart, talking ratio (client vs therapist), and emotion analysis over the course of the session. Only available for notes generated from recordings.
Topics — Key subjects explored during the session. Each topic has a title and a brief summary. You can add, edit, or remove topics.
Note — The structured note itself (SOAP, BIRP, or Unstructured). This is the core clinical documentation.
Client Summary — An optional, client-facing summary you can write and send to the client via email. Once sent, it's also attached to their Client Portal.
Retrospection — A private space for your own reflections. This is never shared with the client or team — it's just for you.
Note Preferences
Configure how Serene handles notes from Profile Settings under Note Preferences:
| Setting | Default | What it does |
|---|---|---|
| Auto-detect client name | On | Attempts to identify the client's name from the recording. When off, uses a placeholder. |
| Add summary to client portal | Off | Automatically attaches the session summary to the client's portal after telehealth sessions. |
| Send session summary email | Off | Emails the session summary to the client after telehealth sessions. |
| Enhanced Recovery | Off | Keeps backups and metadata longer to help recover notes in case of processing failures. |
The portal and email summary settings only apply to telehealth sessions.
Next Steps
- Create A Note — the manual creation flow
- Session Scribe — live session capture
- Pending Notes — the review and approval workflow