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Clinical Notes & Charting

A clinical note is the written record of a visit or interaction with a client — what they reported, what you observed, what you decided, and what happens next. In Ready Practice, notes live in each client's chart, can follow a structured template (including SOAP, the standard Subjective / Objective / Assessment / Plan format), and connect directly to the rest of the platform: an AI scribe can write the first draft from a recorded visit, billing codes on a note flow straight into a superbill, and every edit is kept in a tamper-evident audit history.

This page shows you how to create a note, work with templates (including building your own with conditional fields), use the AI writing tools and AI Scribe, attach billing codes, sign and amend notes, and manage the note lifecycle from draft to archive.

Create a note​

There are two ways into a new note, and both land in the same editor. Use whichever matches where you already are — the client's chart, or the appointment on your calendar.

  1. From the client's chart: open the client and go to the Notes tab, then click Add Note. The note editor opens with your most recently used template already selected, so repeat documentation starts pre-structured.

  2. From the calendar: click an appointment to open its details drawer, then click Write Visit Note. This opens the same editor in the client's chart with the appointment already linked to the note — so the note is tied to the visit without you doing anything extra.

  3. Give the note a title, choose a format or template (see below), and write. Click Save Note when you're done — the note appears at the top of the client's Notes tab.

Linking a note to an appointment

Every note has an optional Link to Appointment selector. Linking matters for billing: a linked note knows which service was delivered, which helps the AI suggest accurate codes and keeps the visit's paper trail in one place. Notes started via Write Visit Note are linked automatically.

Formats and templates​

The Format / Template selector at the top of the editor decides the note's structure. There are three kinds of structure, and you can switch between them freely before you start writing:

  • Standard — a single free-text body. Fastest for quick progress notes.
  • SOAP — four dedicated sections: Subjective (what the client reports), Objective (what you observe or measure), Assessment (your clinical interpretation), and Plan (what happens next). This is the conventional structure most providers chart in.
  • Templates — your clinic's own custom structures, listed by name in the same dropdown. A template turns a note into a guided form: the exact fields you want filled, in order, every time.

The editor remembers the template you used last and pre-selects it on your next new note, so a provider who always charts the same way never has to pick twice.

Build your own template​

You can create or edit a template without leaving the note editor — choose ＋ New template… from the Format / Template dropdown (or click Edit beside a selected template). The same builder is also available under Settings → Note Templates. Templates you build here are shared across your clinic's staff.

  1. Enter a Template name — it doubles as the default title of every note created from it (for example "Progress Note"). Optionally add Default tags, and tick Set as default template to make it the starting point for new notes clinic-wide.

  2. Click Add Field for each question or section. Each field gets a label (e.g. "Chief Complaint"), optional help text, and a type: Short text, Paragraph, Number, Date, Dropdown (pick one), Multiple choice (pick many), Yes / No, Rating / scale, Table (e.g. vitals), Rating grid (e.g. assessment scale), or Instruction text (a display-only block for guidance or boilerplate).

  3. Mark a field Required if it must be filled before the note can be signed — use this for anything compliance depends on.

  4. To make a field conditional, set its Show only when rule — pick a controlling field and a condition such as is, is not, contains, is answered, or is blank. A "Pain location" field that appears only when "Any pain today?" is Yes keeps the form short for everyone else.

  5. Use Preview to see the template exactly as a clinician will fill it, then click Save Template. It's immediately available in every note editor's dropdown.

Start from your paper forms

The fastest way to a good template is to recreate the intake or exam sheet your team already uses on paper, field for field. Table fields work well for vitals; a Rating grid reproduces standardized assessment scales.

The AI writing toolbar​

Every text area in the note editor carries an AI toolbar, so you can draft fast and let the AI polish. Each action shows you the rewritten text to review before it replaces anything — you stay in control of what lands in the chart.

  • Improve — cleans up clarity, grammar, and professional tone while keeping the clinical content intact. Write in shorthand, improve once, done.
  • Summarize — condenses a long section to its key findings and recommendations.
  • Simplify — rewrites the text in plain, patient-friendly language with no jargon. Useful when you plan to share the substance of a note with the client.
  • Suggest Codes — proposes defensible ICD-10 (diagnosis) and CPT/HCPCS (procedure) codes based on what the note actually documents, with supporting evidence quoted from the note.
AI suggestions are drafts, not decisions

The AI never changes your note silently and never picks final billing codes for you. Review every rewrite and every suggested code before accepting — you are the author of record, and the signed note is your clinical and legal document.

AI Scribe — record a visit, get the note written​

AI Scribe listens to an in-person visit and writes the note for you, in whatever format you choose. Instead of typing during the appointment, you talk to your client; the recording is transcribed and turned into a structured draft you review afterwards.

  1. On the client's Notes tab, click Record Visit. The recording window opens.

  2. Choose the Note format for this session — SOAP (default) or any of your custom templates. The pre-selected format follows your clinic's scribe setting, and you can change it per recording. The scribe will fill whichever structure you pick.

  3. Click Start Recording and conduct the visit. While you talk, a live Transcript builds on the left and a Live SOAP preview forms on the right (it starts appearing after about 20 seconds), so you can see the note taking shape in real time. The scribe also surfaces Recommendations — services or follow-ups it heard discussed during the visit.

  4. Stop the recording when the visit ends. The audio is transcribed and the note is created in your chosen format, marked with an AI Scribe badge in the notes list. The raw transcript is kept with the note in a collapsible section, and you can edit it.

Review the [VERIFY] flags​

Anywhere the scribe wasn't confident — a dosage it may have misheard, a claim it couldn't ground in the conversation — it leaves an inline verify marker in the note text rather than guessing silently. Each marker is clickable:

  • Accept removes just the marker, confirming the flagged statement is correct.
  • Remove line deletes the entire flagged line from the note.

Markers you don't click stay put, so an unreviewed scribe note visibly shows what still needs a human eye. Uncertain billing codes get the same treatment — they're labeled Verify in the codes list until you accept, edit, or remove them.

Review scribe notes before signing

An AI-scribed note is a draft of what the scribe heard, not a verified record. Work through every verify marker and confirm the codes before you sign — a signed note is locked and becomes part of the permanent chart.

Billing codes on a note → superbill​

Notes are where clinical documentation meets billing. The editor's codes section lets you attach ICD-10 diagnosis codes and CPT/HCPCS procedure codes (with a searchable picker and free entry), either by hand or from the Suggest Codes AI action.

  1. Add the codes that reflect what the note documents. Each suggested or scribe-generated code shows Accept, Edit, and Remove controls, so nothing unreviewed slips through.

  2. For procedure codes, set the units with the × counter — for example ×2 for a service delivered twice in the visit. Units carry through to billing exactly as set.

  3. When the codes are reviewed, click + Create superbill. A superbill — an itemized statement of the visit's diagnoses and services that a client or biller can submit to insurance — is drafted from the note's codes automatically. To bill it as a claim, open Billing → New claim → From superbill.

Repeated codes become units

If the same CPT code appears more than once on a note, the superbill collapses the repeats into one line with the correct unit count — which is how payers expect to see it.

Share with the client​

A note itself is internal, but you can send its outcome to the client through their secure chat — the encrypted message thread they see in your client app and portal.

  1. In a note that has Recommended from visit items (surfaced by AI Scribe or added by you), select the recommendations you want the client to see and click Suggest to client.

  2. A preview opens with an editable message ("Your provider recommends: …"). Nothing sends until you've read it — adjust the wording, then click Send. The client gets the message in their secure chat with a notification.

Suggesting never charges or books

Sending a recommendation is only a message from you. It does not charge the client and does not book anything — they act on it themselves, or you follow up.

Make it client-readable first

If you're sharing clinical substance, run the relevant section through the Simplify AI action first — it rewrites the text in patient-friendly language, so what lands in the client's chat is something they can actually use.

Sign the note, and amend it with addenda​

Signing is the compliance step that turns a draft into the record. An unsigned note shows Draft — not yet signed at the bottom of the note view.

  1. Open the note and click Sign note, then Confirm & sign. The note is locked with your name and a timestamp — it can no longer be edited directly.

  2. To add to a signed note, click Add addendum. An addendum is an append-only correction or update: it's stamped with its author and time and displayed under the original, leaving the signed content untouched. This is the standard, audit-safe way to correct the record.

Required template fields gate signing

If the note was written from a template with Required fields, those fields must be filled before the note can be signed.

Audit History — every revision, as a diff​

Every edit to a note is recorded. At the bottom of the note, the collapsible Audit History section lists each revision with who changed it and when — and shows the change as a real side-by-side difference, with additions highlighted and removals struck through, section by section. There's nothing to configure; the history accumulates automatically and can't be edited.

Archive or delete a note​

The notes list keeps day-to-day charting uncluttered without losing anything:

  • Archive (the box icon on a note row, or the archive action inside the note view) moves a note out of the active list. Switch the status filter to Archived to see archived notes, and use Restore to bring one back.
  • Delete (the trash icon) removes the note after an inline "Delete this note?" confirmation. Prefer archiving for anything that was ever a real clinical record — deletion is for mistakes, like a note created on the wrong client.
Ask Atlas

Atlas has the full context of a client's chart, so you can chart and retrieve hands-free. Try:

  • "Summarize the last three notes for this client."
  • "Draft a SOAP note for today's visit: client reports lower back pain improving, full range of motion on exam, continuing the current protocol, re-evaluate in two weeks."
  • "Which of this client's notes mention shoulder pain?"
  • "What CPT codes did we bill on this client's last visit note?"

Next steps​

  • Turn recorded visits into notes automatically → set up AI Scribe, including your clinic-wide default note format.
  • Bill what you documented → take a note's superbill through a claim in Insurance & Billing.
  • Control who can read and write notes → review chart access in Staff & Permissions.
  • Chart straight from the schedule → see how appointments and their details drawer work in Rescheduling, Cancellations & Waitlist.