Write Your First Clinical Note
This guide walks you through creating, writing, and signing your first clinical note in Praxi. Clinical notes are a core part of your documentation obligations as a registered practitioner.
Prerequisites
- You've added a client to your practice
- Your account has the Practitioner, Supervisor, Intern, or Practice Owner role
- The client has an existing appointment (recommended but not required)
Step 1: Open the Client Record
Click Clients in the sidebar (always visible in the Essentials section). Find and click on the client you want to write a note for.
Step 2: Navigate to Notes
On the client profile, click the Notes tab. This shows all existing clinical notes for the client, ordered by date.
Step 3: Create a New Note
Click the New Note button. You'll be prompted to choose a note template.
Choosing a Template
Praxi provides several built-in templates:
| Template | Best For |
|---|---|
| SOAP | Structured medical-style notes (Subjective, Objective, Assessment, Plan) |
| DAP | Brief therapy notes (Data, Assessment, Plan) |
| Progress | General session progress notes |
| Risk | Risk assessment and safety planning |
| Intake | Initial assessment and history-taking |
| Discharge | Treatment summary and discharge planning |
Select the template that best fits your session type. You can also start with a blank note if you prefer.
Step 4: Write Your Note
The note editor is a rich text editor with clinical formatting tools. Write your note content in each section of the template.
Key features of the editor:
- Rich formatting — headings, bold, italic, lists, and tables
- Clinical snippets — type
/to insert pre-built text snippets for common phrases and observations - Auto-save — your note is saved as a draft automatically every few seconds
Snippets save time — Your practice can create custom snippets for frequently used phrases. Check Practice settings to manage organisation-level snippets, or create personal snippets from your profile.
Step 5: Use AI Assistance (Optional)
Praxi, your AI assistant, can help with your notes.
What Praxi Can Do
- Suggest content based on the session transcript (if you used voice transcription)
- Check completeness — flag missing sections or required fields
- Generate a draft from your session recording that you can review and edit
- Summarise long notes into concise clinical summaries
To use Praxi, click the Generate with AI button in the note toolbar. Praxi's suggestions always require your review and approval before being added to the note.
AI-generated content is always flagged as AI-assisted in the audit trail. You are responsible for reviewing and approving all content before signing. Consult your professional body's code of conduct for guidance on AI-assisted documentation.
Step 6: Review Your Note
Before signing, review your note for:
- Clinical accuracy — does the note accurately reflect the session?
- Completeness — are all required sections filled in?
- Privacy — does the note contain only clinically relevant information?
- Consent — if the client is a couple or minor, check consent settings
Step 7: Sign the Note
When you're satisfied with your note, click Sign Note. This action:
- Locks the note — signed notes cannot be edited (AHPRA requirement)
- Timestamps the signature — records exactly when the note was signed
- Creates an audit entry — immutable record of the signing event
24-hour signing requirement — Your professional body guidelines recommend signing clinical notes within 24 hours of the session as a medicolegal best practice. Praxi will remind you of unsigned notes. Unsigned notes older than 24 hours are flagged in your dashboard.
What If You Need to Change a Signed Note?
Signed notes are immutable. If you need to correct an error:
- Create an addendum to the original note
- The addendum is linked to the original and clearly marked as a correction
- Both the original and addendum are retained for the 7-year record-keeping period
Next Steps
- Schedule the next appointment for this client
- Create an invoice for the session — see Create your first invoice
- Set up voice transcription to have Praxi assist with future notes automatically
Tips
- Draft notes are visible only to you until signed. Other practitioners cannot see your drafts.
- Templates can be customised per practitioner. If none of the built-in templates suit your workflow, ask your practice manager to create a custom one.
- Session memory: If you use Praxi's voice transcription, Praxi builds a memory of the client's treatment journey across sessions, making each subsequent note richer with context.