Clinical Notes & EHR
Progress notes written after hours in a generic word processor don't connect to a treatment plan or a billing code. We build the documentation system that does both, in session.
What we build
- Structured progress notes: Templated note formats (SOAP, DAP, and custom) tied to each client's treatment plan.
- Treatment plan tracking: Goals and interventions tracked across sessions, not re-typed each time.
- Co-signature workflows: Supervisor review and co-signature routing for associate-level clinicians.
- Secure record access: Role-based access so a client's full record is visible only to their care team.
Implementation scope
Clinical documentation connects to scheduling and billing, so a completed note automatically triggers the correct billing code for that session.