Write and finalize a SOAP note
Generate the AI draft, review every section once, then finalize with attestation.
Goal
Turn a session into a signed note. Two doors lead here: recording a session (Generate session note) or typing one out (Write a note → /dashboard/notes/new). Both end at the note page (/dashboard/sessions/[id]/soap) with the Draft/Final pill.
Before you start
You need a transcript with at least ~40 words of speech. Under that, Generate note disables and you see This recording is too short to generate a note. Typed notes skip the gate. Fix speaker labels first — the draft labels lines Clinician:/Child: and wrong labels carry into the note.
Steps
- Open the session review page and click Generate Notes (or Open notes if a draft exists). Pick the format: SOAP, School Note, or Informal Evaluation Summary.
- Optional: set the EHR template, writing voice, custom instructions, and target rows (count/estimate/not-scored). Then click Generate note (sparkles) and wait for sections to stream in.
- Fix the transcript if needed: per-line speaker toggle, Swap speakers bulk flip, Save cues. If you edit after generating, the banner
The transcript was edited after this note was generatedappears — click Regenerate. - Review each section once, in one pass: click Edit only where needed, then Save. Every section must show reviewed (ticked). Editing unticks it (
N sections changed since you reviewed), so review last. - Clear amber Needs verification marks (
needs probing,unable to determine,clinician should verify). These are the AI telling you it is unsure — never finalize with them unaddressed. - Click Check & finalize, tick the attestation checkbox (
I, {name}, have reviewed every section... I take clinical responsibility...), then Finalize note. The view becomes read-only:Finalized {date} signed by {name}. The Clinical Insights learning box is stripped from the signed copy automatically. - Corrections after finalizing go through Save addendum / Add addendum (dated, signed). The original text never changes — an addendum is a signed correction stapled on top.
Finalize checklist
At /help/write-soap-note#finalize: transcript ≥ 40 words, speakers correct, every section ticked in one pass, no amber marks left, attestation checked. Draft saves (Save as draft → Draft saved, autosaves every ~2.5s) are in-progress, not signed — only Finalize note signs.
Troubleshooting
| Problem | Fix |
|---|---|
No transcript available. Record a session or upload a transcript first. | No audio yet. Go back and record or upload. |
N sections changed since you reviewed loop | You edited after ticking. Re-tick edited sections once, then finalize without further edits. |
Failed to save note — please click Save | Stay on the page, click Save. The text is still on screen. |
| Session Logger confusion | The Medicaid Session Logger under Documentation never locks (sign + keep editing). Session SOAP notes lock on finalize. They are different tools with different rules. |
Next
- Review progress: finalized notes feed goal movement and parent updates.
- Plan next steps: Note for parents and Carryover become the next plan.