Choose a note format.
Select SOAP, DAP, or BIRP, or create sections for the notes you write in your practice.
Fictional patientSample session
+ New formatPatient reports mood improved from 3/10 to 6/10 and sleep of 7 hours most nights.
Reports 1 missed sertraline dose this month. Dry mouth resolved.
Clinician observed engagement in the discussion and noted the reported improvement.
Plan discussed: review mood and sleep in 4 weeks.
The patient reports improved mood, from 3/10 to 6/10, and 7 hours of sleep most nights. Reports 1 missed sertraline dose this month and resolution of dry mouth. Engaged in discussion. Review mood and sleep in 4 weeks.
Subjective
Mood improved from 3/10 to 6/10. Sleeps 7 hours most nights. Reports 1 missed sertraline dose this month. Dry mouth resolved.
Objective
Engaged in discussion.
Assessment
Patient reports improved mood and sleep.
Plan
Review mood and sleep in 4 weeks.
Reports 1 missed sertraline dose this month. Dry mouth resolved. Mood improved from 3/10 to 6/10, with 7 hours of sleep most nights.
Mental Status Exam
Engaged in discussion. Other findings are not documented in this example.
Assessment
Patient reports improved mood and sleep.
Note templates
Clinical note templates for your practice
Choose SOAP, DAP, or BIRP, or define sections and instructions for the notes you write in your practice.
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Build templates around your clinical work
Set up the sections your practice uses for intake notes and progress notes.
Write section instructions.
Describe what belongs in each section, such as the intervention used and the client’s response.
Generate your first note.
Use a sample session to see your format in action, then set the template as your default.
Specify what goes in each section
Choose a standard format or define the structure your practice uses.
“I used to rewrite every note into my own structure before signing. That step is just gone.”
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Choose your documentation tools
Transcribe the conversation or dictate your findings before generating a note.
FAQs
Frequently Asked Questions
Which note formats are included?
ClinicFrame includes SOAP, DAP, and BIRP note formats, plus a template for documenting a Mental Status Exam. The exam records your clinical assessment of mental function. Its template organizes the findings you provide.
Do I have to change how I write my notes?
Create a template with the sections you use in your practice. For an intake note, you might include the client’s stated goals. For a progress note, specify where to document the intervention and the client’s response.
How specific can the instructions be?
Give each section a clear instruction, such as identifying the intervention used or limiting a summary to 2 sentences. Include your clinical observations and decisions in the session information. Review the generated note to check that the instructions produced the intended result.
What if I want a note without fixed headings?
Choose Enhanced note for a prose summary without fixed section headings. Review the summary for the information your clinical record requires before using it.
Can I create my own template?
Name the sections and write plain-language instructions for what each should contain. Use a sample session to check the result and refine the instructions before adopting the template.
Can I generate more than one document from the same session?
Generate a chart note, a referral summary, or a patient recap from the session, each in its own format. Review each document for its intended recipient before sharing it.
Do templates work with Dictation and Transcription?
Select a note template for either a Dictation or Transcription session. The format determines the structure. The content depends on your narration or the conversation you captured, together with any clinical information you add.
Can the note come out in Spanish?
Choose English or Spanish for the output. Check the clinical terminology and meaning in the generated note before using or sharing it.
Use your note templates on desktop
Use your note templates in the browser or desktop app. Download ClinicFrame to get desktop notifications alongside your sessions.
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