AI therapy notes, done carefully, are drafts: the system turns the clinician's own dictated summary, or a session recording made with the client's explicit consent, into a progress note in the practice's format. The therapist edits and signs it. The system adds no clinical opinion.
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Recording a therapy session is not a neutral act. It can change what a client feels able to say, so recording happens only with explicit, informed consent that the client can refuse or withdraw at any time without any effect on their care. Many clinicians prefer not to record at all, which is why the default input is the clinician's own short dictated or typed summary after the session.
From either input the system drafts a progress note in the format the practice uses, such as SOAP, DAP or BIRP, along with treatment plan updates, letters and insurer paperwork where they are needed. It keeps to what was said. It does not add interpretations, suggest diagnoses, label risk or score the session. Where the input leaves a section empty, the draft leaves it empty and says so.
Several dedicated products exist, and for an individual practitioner one of them, under a signed data agreement, is often the right choice. A custom build suits group practices and services that need notes in their own templates and system, a no-recording option by default, their own escalation rules, or data kept on infrastructure they control. We will tell you which applies.
It can be, if the client knows, consent is real, the clinician remains the author of the record and the data is handled with the care special-category data requires. Professional bodies have published guidance on AI use, and their codes still apply to a note drafted by software. That is why our default works from the clinician's own summary and records sessions only with explicit consent.
No tool is compliant by itself; compliance depends on how the practice uses it. Under HIPAA the practice is the covered entity and needs a business associate agreement with any vendor handling the data, and psychotherapy notes kept separately carry extra protection. We do not hold certifications or claim compliance for you, and we design so the agreements you sign can be honoured.
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Start with your note template and how your clinicians would prefer to give their summary.
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