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Create A Note

Generate a client note from scratch using Serene's step-by-step guided process.

What is Create A Note?​

The "Create A Note" feature allows you to manually write session notes without recording or uploading audio. This is perfect for in-person sessions or when you prefer to document sessions directly.

How to Create a Note​

  1. Click "Create" on the "Create A Note" card in Quick Actions
  2. Follow the guided steps:
    • Select or create a client profile
    • Choose your note format (BIRP, SOAP, or unstructured)
    • Fill in session details and observations
    • Add any relevant assessments or progress notes
  3. Review and save your completed note

Note Formats Available​

BIRP Notes​

  • Behavior: What you observed
  • Intervention: Techniques or approaches used
  • Response: Client's reaction to interventions
  • Plan: Next steps and recommendations

SOAP Notes​

  • Subjective: Client's reported concerns
  • Objective: Your clinical observations
  • Assessment: Your professional evaluation
  • Plan: Treatment plan and goals

Unstructured Notes​

Free-form documentation that allows you to write notes in your own style without following a specific format.

When to Use Create A Note​

  • In-person sessions where you don't need to record
  • Quick documentation of brief check-ins
  • Manual note-taking when you prefer typing directly
  • Supplementary notes to add to existing session records

Tips for Effective Note-Taking​

Writing Quality Notes
  • Be specific and factual in your observations
  • Focus on clinically relevant information
  • Document interventions and client responses
  • Include measurable progress when possible
  • Keep notes concise but comprehensive

After Creating Your Note​

Once created, your note will appear in:

  • Pending Review section for final approval
  • The client's session records after approval
  • Your notes vault for easy access and searching
Last updated on by Anurag Mandal