SOAP note
Subjective
Objective (MSE)
Assessment (Risk)
Plan
Document patient encounters, interventions, and plans in the SOAP format: subjective data, objective data, assessment, and plan.
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Captures MSE criteria including appearance, emotions, thoughts, cognition, judgement and insight. Also identifies medication names, dosages, changes, side-effects and contains lab results and risk assessment.
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Captures subjective (patient-related symptoms and histories), objective (observations, measurements, and test results discussed), assessment (diagnosis and evaluation), and plan (treatment and follow-up).
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Encompasses diverse clinical domains and more detailed rationale for care. Also emphasizes individualized factors, clarifies targeted objectives, and supports richer understanding and more responsive, tailored interventions.
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Aligns with Headway's note structure, capturing clinical summaries, diagnostic support statements, medical necessity, and progress toward treatment objectives.
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What would you do with six extra hours each week? With less time spent on admin, you can take on more clients or enjoy some well-deserved relaxation time.
Struggling to split attention between your clients and detailed note-taking? AI notes let you focus on the client without worrying you'll miss important details.
With manual note-taking distractions a distant memory, you can stay present during sessions and provide a more engaging client experience every session.
SOAP notes are a progress note template with sections corresponding to the SOAP acronym: subjective, objective, assessment, plan. If you’d like you learn more about SOAP notes, you can read our SOAP note guide.
AI-generated SOAP notes use artificial intelligence to interpret relevant information from a therapy session and produce a SOAP note for the session.
Upheal AI notes are Privacy Act and Health Information Privacy Code compliant. However, not all AI notes are. Ensure the AI tools you use to create clinical notes are compliant by reviewing the privacy section of their website.
You can learn more about Upheal’s compliance on our privacy and compliance page.
You can generate unlimited clinical notes using Upheal AI for free!
If you’d like advanced features like different note types, treatment plans, and client summaries, you can sign up to one of our paid plans.
To find the right plan for your practice, visit our pricing page.
Absolutely. You can capture online sessions without even leaving your EHR. Our extension works with any telehealth or video-calling platform. You can also capture audio during in-person sessions or choose to upload audio recordings manually.
Either way, it’s easy to copy-paste the note content to your EHR.
Administrative tasks like note-taking are time-consuming. They are also usually done during sessions, or in your personal time. This contributes to burnout, limits the number of clients you can see, and ultimately impacts patient care.
AI scribes like Upheal, are up to 90% faster than manually writing clinical notes, giving you back 6+ hours a week and allowing you to stay present during consultations.
This is time you can use to, take on new clients, develop your skills, or spend with family.
No, we are not. Our goal is to support the therapist in the work that they do and provide better life balance with AI-powered automation.
We do a limited amount of data training for specific scenarios like medication and name recognition, prompt evaluation, or to test the accuracy of our notes.
Clients have the option to participate or decline in the sharing of their data for improvements to the Upheal app.
Upheal’s AI technology is specifically trained for therapeutic and psychiatric sessions, unlike universal solutions like ChatGPT. Plus, our notes are regularly reviewed by practicing clinicians to ensure accuracy.
Upheal works with a secure infrastructure provider and follows strict security guidelines, complying with HIPAA, PHIPA, PIPEDA, GDPR, SOC2, and other regulations.
Capture therapy sessions held in English Spanish, Portuguese, German, French, Italian, Mandarin, and Hindi. Translate your notes from English with Smart edit.
Want to create your own clinical note templates? With custom note templates, you can rearrange existing content sections to fit your specific needs.
Create custom instructions to save time on note edits: shorten sections, convert paragraphs into lists, anonymize information, or translate notes into another language.
Capture online sessions without leaving your EHR with our browser extension. Record in-person audio or upload recordings, and easily copy and paste notes to your EHR.
Upheal streamlines clinical documentation so you can save time on note-taking and be more attentive during sessions.
