TherapyMate has partnered with Clinical Notes AI (clinicalnotes.ai) and integrated their technology into your subscription to assist you during patient encounters by generating clinical notes based on your conversations. This tool is sometime referred to as AI Scribe and allows you to focus more on your patient, less on taking written notes, typing into a computer or relying on your memory to create documentation.
Our AI technology captures and analyzes the nuances of your therapy sessions, transforming them into precisely formatted notes. The level of detail we provide ensures you have access to all necessary documents, including assessments, treatment plans, patient-facing session recaps, post-session dictation, compliant billing, and more. Clinical Notes AI is optimized for Telehealth.
Client Consent
Do I need my client's consent?
It depends on how you use the Clinical Notes AI feature within TherapyMate.
Dictation only (no client present): Consent is not required if you are using the AI solely to transcribe or summarize notes after a session (e.g., dictating your own notes).
Live sessions (client present): Consent is required if you are using Clinical Notes AI during a live session with a client. This can be obtained verbally, or you can send a consent document to the client via the Client Portal that they sign.
To help with this, your Client Portal Documents and Questionnaires include a form titled "Client Consent to Automated Note Taking using AI Technology". You can send this form to clients via the Client Portal, allowing them to consent to opt in or opt out of the use of this technology during sessions.
Please review the document and make any edits you feel are necessary before sharing it with clients.
Using Clinical Notes AI
Before a clinician can use Clinical Notes AI, the Practice System Administrator must enable the feature for each Clinician. Contact your System Administrator for assistance.
Using Sex and Pronoun Information
When AI generates the text from the audio conversation, you will get better results if the Sex and Pronoun fields on a Client's Information page are defined.
This will enhance AI's ability to refer to the client more accurately when it populates the note. It will also use the word "Client" in some cases.
The following note types can be used with AI:
- Intake Note
- Treatment Plan
- Standard Progress Note
- Soap Note
- Process Note
AI does not work with Custom Note Templates. Works with all popular Internet Browsers including Safari for the Mac.
Data Capture Options
- AI listens to a Live Session and extracts clinically relevant data from the audio to build a progress note or document.
- Talk to AI using Dictation by describing the session you were just in to create a note or document.
- Upload an audio file that you recorded and saved to an external device.
To use any of the capture options above, you must open a note template to begin.
Live Sessions
Click on the note type to open the template that you wish to create during the session.
In this example, we are going to click on the Standard Progress Note. The note template opens and there is an icon in the upper right corner. Click on the colored widget to enable AI for this note. The widget is located in the upper right corner.
You will see a control panel appear on the right side of the note. The default is set to Live Session.
When the client and clinician are ready to begin the session, the clinician clicks the Start button and the conversation will begin to get captured.
DO NOT close your notebook lid or set your computer to go into hibernate/sleep mode after AI starts. The session will fail to record.
If your computer's screen saver starts, the recording will continue.
The TherapyMate security feature to log you out automatically after so many minutes is disabled as long at the AI dialog window is open. After the note is saved, the auto logout feature is enabled again.
Proceed with the session. The system will pick up the audio from your computer's microphone. If you're prompted to allow your microphone to be used say yes.
When the session is over, click the End button.
The dropdowns, checkboxes and text boxes that will be considered for AI input from the session audio will be outlined in red.
Click the Generate Fields button to process the audio from the session and populate the note using AI.
It will take a few seconds for the system to convert the audio from the session to text. When it finishes, you'll see a preview of the conversion. You can edit and/or add content to the note if necessary. When you're satisfied with the contents of the note, click the Confirm button.
When you satisfied with the note be sure to click the Save button.
Here is an example of a note that was creating using AI from a Live Session:
Dictation
Click on the Dictation tab in the control panel and then click the Start button and start talking.
When you're done dictating the note, click the End button. Next, click on the Generate Fields button to fill in the note. Review the note and make any changes you need and then click the Confirm button. When you satisfied with the note be sure to click the Save button.
Uploading an Audio File
If you recorded and saved a session's audio to an external device, you can upload it to generate a note. Click on the Live Session tab, then the icon to the right of the End button.
A upload dialog will appear so you an browse to where your file is located. You can search for the file on your computer and click on it or drag and drop the file into the dialog below. Make sure any music app on your computer is not running if you drag and drop it. If the music app is running the audio file will begin to play instead of uploading.
When the file is done uploading you can click the Generate button to populate the note template you have open.
Goals and Objectives
If goals and objectives were created on the Treatment Plan, they will still carry forward to the Standard Progress Note so you can manage them. If you'd like AI to suggest additional goals and objectives from the session audio, open blank goal and objective fields on the note prior to the session starting. If applicable, it will be filled in by the audio using AI.