Skip to main content

Creating Clinical Notes

Learn how to create comprehensive clinical notes efficiently.

Starting a Note​

From an Appointment​

  1. Open a completed appointment
  2. Click Create Note or press N
  3. Note is pre-populated with appointment details

From the Notes Section​

  1. Go to Notes in the sidebar
  2. Click New Note or press N
  3. Select the client
  4. Choose the session date

From Command Palette​

  1. Press Cmd+K
  2. Type "new note"
  3. Select client
  4. Begin writing

The Note Editor​

Notes open straight into the rich-text editor with your template's sections in place and template fields (client name, session date, practitioner details) resolved automatically. Write manually, or use AI generation from inside the editor:

  • Generate with AI -- the toolbar button opens the AI generation drawer
  • Custom AI instructions -- provide natural language instructions to guide generation for specific sections (e.g. "Focus on CBT interventions used")
  • Template structures themselves are managed in Settings, not per note

AI Generation​

When you click Generate with AI, Praxi generates each section independently:

  1. Fixed fields (client name, date, etc.) resolve immediately
  2. AI sections process one at a time with a progress animation
  3. For each completed section, you can:
    • Accept -- confirm the generated content
    • Refine -- provide natural language feedback (e.g. "Make this more formal" or "Expand the risk assessment") and regenerate
    • Delete -- remove the section
  4. Linked evidence -- each section shows which transcript segments support the generated content. Click a citation to view the source.
  5. Once all sections are reviewed, optional post-processing runs:
    • Improve clinical language
    • Spelling and grammar check
    • Cross-section consistency check

Press Cmd+Shift+A to accept all generated sections at once.

Formatting​

Use standard formatting tools:

  • Bold (Cmd+B)
  • Italic (Cmd+I)
  • Lists (bullet and numbered)
  • Headings

Snippets​

Insert pre-written clinical text:

  1. Type / in the editor
  2. Search for a snippet (MSE, risk assessment, session plan, homework, etc.)
  3. Press Enter to insert
  4. Field snippets (client name, session date) also available via /

Learn more: Using Snippets

Keyboard Shortcuts​

ShortcutAction
Cmd+Shift+AAccept all AI sections (while generating)

Exporting Notes​

Export your note in multiple formats:

  • Raw Text -- plain text copy to clipboard
  • Formatted -- rich text copy to clipboard (preserves formatting)
  • Markdown -- markdown copy to clipboard
  • PDF -- download as a professional PDF with practice letterhead

Writing Tips​

Be Concise​

  • Focus on clinically relevant information
  • Use clear, professional language
  • Avoid unnecessary detail

Be Specific​

Good: "Client reported 3/10 anxiety after breathing exercise" Poor: "Client felt better"

Be Objective​

  • Document observable behaviours
  • Use clinical terminology appropriately
  • Distinguish observations from interpretations

Include Key Elements​

Every note should address:

  1. What was the focus of the session?
  2. What interventions were used?
  3. How did the client respond?
  4. What is the plan going forward?
  5. Any risk factors present?

Risk Assessment​

Include risk assessment in every note:

Clinical note detail view showing risk assessment section

Risk Levels​

LevelIndicatorsAction
NoneNo current concernsContinue treatment
LowSome factors presentMonitor
ModerateMultiple factorsSafety plan
HighImminent riskCrisis intervention

Documenting Risk​

  1. Current risk level
  2. Factors assessed
  3. Protective factors
  4. Actions taken
  5. Safety plan if applicable

Auto-Save​

Praxi automatically saves your work:

  • Every few seconds while typing
  • When switching away from the note
  • Before any navigation
Auto-Save

You'll see a "Saved" indicator when changes are saved. No need to manually save while working. :::

Attachments​

Attach files to notes:

  1. Click the paperclip icon
  2. Select file(s) to attach
  3. Files are linked to the note
  4. Common attachments: assessments, letters, consent forms

Templates​

Use note templates for consistency. Built-in templates include SOAP, DAP, BIRP, GIRP, EMDR, Initial Assessment, Discharge Summary, Narrative, Crisis Note, Couples Session, and Group Session formats. You can also create custom templates scoped to your practice or personally.

Templates can be customised by your practice administrator. See Note Templates for full details.

AI Note Assistance​

Praxi, the clinical AI assistant, can help with note creation:

  • Draft generation -- Praxi can draft a note from the session, using your selected template structure. Assessment, diagnosis, risk and plan sections record only what you stated
  • Clinical language -- Helps refine observations into professional documentation
  • Style learning -- Praxi learns your writing style over time and adapts future AI-generated notes to match your terminology and section preferences
  • Smart Sections -- Regenerate individual note sections independently using per-section AI prompts. Useful when you are satisfied with most of the note but want to retry one section
  • Action extraction -- After signing, AI identifies tasks, homework, assessments, referrals, GP letter triggers, and MBS item suggestions from the note content for you to approve

All AI suggestions require your review and approval before being included in the note. Praxi's suggestions appear as editable proposals, never auto-committed.

AI Attestation Requirement

If a note was generated by AI, you must explicitly attest to its accuracy before signing. This is a professional standards requirement to confirm you have reviewed the AI-generated content. :::

AI Assistance is Optional

AI assistance can be disabled in Settings > AI Preferences. All AI interactions are logged for audit purposes with 7-year retention. :::

Voice Transcription​

Dictate notes using real-time voice transcription:

  1. Click the microphone icon in the note editor
  2. Speak naturally about the session
  3. Transcription appears in real time
  4. Edit and refine the transcribed text
  5. Review before finalising

Voice transcription processes audio using cloud speech-to-text services. Explicit client consent is required before transcription begins.

Note Locking​

When you open a note for editing, Praxi automatically acquires a lock to prevent concurrent editing by another practitioner. Locks expire after 15 minutes of inactivity and are automatically extended while you are actively editing.

If another practitioner has locked a note, you will see a message indicating who is currently editing it. Practice owners and administrators can force-release locks if needed. Administrators can also view a list of all currently locked notes across the organisation.

Duplicating a Note​

You can duplicate any existing note to use as a starting point:

  1. Open the note you want to duplicate
  2. Click Duplicate
  3. A new draft is created with the same content
  4. Edit and save the new note as needed

Restoring Deleted Drafts​

If you accidentally delete a draft note, it can be restored within 30 days:

  1. Locate the deleted note (it will be marked as deleted)
  2. Click Restore
  3. The note returns to its previous draft status

After 30 days, deleted drafts are permanently removed and cannot be recovered.

AHPRA Compliance Check​

Praxi can run a real-time documentation completeness check against AHPRA Standard 4.4.4 before you sign:

  1. Open the note
  2. Click Check Compliance (or Praxi may run this automatically)
  3. Review the scored result showing individual checks for items like risk assessment, treatment rationale, consent documentation, and sufficient detail
  4. Address any warnings or suggestions

Compliance checks are informational only -- they never block signing. You retain full authority over your documentation.

Clinical Letter Generation​

Generate AI-drafted clinical correspondence from within the notes system:

  1. Open a client's record
  2. Select Generate Letter
  3. Choose the letter type:
    • Referral letter -- for referring to another practitioner
    • Discharge summary -- end-of-treatment summary for GPs
    • NDIS progress report -- with source citations per NCAT ruling
    • School letter -- for school support
    • Workplace letter -- for employer communications
    • MHTP review -- Mental Health Treatment Plan review
    • Court report framework -- structured framework for legal reports
  4. Optionally specify a recipient, date range, or special instructions
  5. Review and edit the AI-generated draft
  6. Letters are always drafts -- they are never auto-sent

Pre-Session Briefs​

Before an appointment, Praxi generates a pre-session intelligence brief summarising the client's treatment history, recent themes, risk factors, and suggested focus areas. Briefs are generated automatically 25-35 minutes before the appointment, or on-demand when you first view them.

After reviewing a brief, you can mark it as viewed and optionally submit feedback to help improve future briefs.

Recording Goal Progress​

When writing a session note, you can record progress against the client's treatment goals:

  1. Open the note
  2. Navigate to the Goal Progress section
  3. For each relevant treatment goal, record the current progress and any notes
  4. Save the progress entries

Goal progress is linked to the session record and visible in the client's treatment plan timeline.

Collaboration​

Supervision​

Provisionally registered practitioners and interns must submit their notes for supervisor review before signing:

  1. Write and complete the note
  2. Click Submit for Review and select your supervisor
  3. Your supervisor is notified and reviews the note
  4. The supervisor either approves the note or requests changes
  5. If changes are requested, revise and resubmit
  6. Once approved, you can sign the note
Supervision Required

If your registration status requires supervision, Praxi will not allow you to sign a note until it has been approved by your supervisor. :::

Sharing​

Share notes when appropriate:

  • Export as PDF -- Generate a professional PDF with practice letterhead
  • Share via email -- Send a note as a PDF attachment (note must be signed for external sharing)
  • GP Summary -- Generate an AI-assisted clinical summary letter for the referring GP, available as preview or PDF download
  • In supervision sessions
  • For referral letters (summary only)

Saving and Closing​

ActionShortcutDescription
SaveCmd+SSave current state
Save & CloseCmd+EnterSave and return to list
DiscardEscConfirm to discard changes
Signing Deadline

Remember to sign clinical notes promptly after the session. Notes follow the status workflow: Draft -> Final -> Signed (locked, immutable) -> Amended (if an addendum is added). All clinical records are retained for a minimum of 7 years under the Privacy Act 1988. :::

Next Steps​

Was this page helpful?