You can type and/or dictate observations or a brief description a session, and Upheal will generate complete, structured notes using AI. This is an ideal option if you don't want to capture session audio, or if you have old documentation to catch up on.
You can also use this feature if want to type up your own note without the use of AI.
Please note:
On our trial and Free plan, you can dictate for up to 15 minutes per session.
While you can type your observations in any of our supported languages, verbal dictation is currently only supported in English.
Turning observations into full notes
There are multiple ways to start:
From a client's profile: Click Note from past session, then click Write or dictate
From the left menu: Click New Session in the top left, then click Write or dictate.
From the Sessions page: In the left menu, click Sessions, then New session, then click Write or dictate
Using the dropdown menus, choose a client, or make it an anonymous note.
Then select the pronouns that will be used to refer to your client in the note, and the note template.
Optionally, you can select modalities, specify whether the session was in person or online, and set the date and time.
Click Continue.
Type and/or dictate your summary. Remember to include details to cover each section of the note type you're using.
Dictating a session summary:
To record your speech, click Dictate.
Your speech is recorded and transcribed. Once you stop dictating, you'll see the transcription in the text box. Dictating won't overwrite anything you've already typed.
When you're finished speaking, click Stop.
You can start and stop dictation again as needed without losing what you've already dictated, and edit the transcript of your speech by typing.
Or, skip speaking and type your whole session overview in the text box.
When you're finished, click Generate note.
In a few moments, your note will be ready. You can edit the note as usual. Changes you make by typing in the note are saved automatically.
Generating a new note
You can add details and generate a new note from your written or dictated summary at any time. When you generate a new note, this overwrites the current note, including any edits you made.
To add details and generate a new note:
On the session page, on the right side, type or dictate the additional details.
Optionally, you can change or add a session title, date and time, duration, session format, client location, services, CPT codes, modalities, or diagnoses, by clicking Edit in the top right. Make your changes, and click Update.
Click Generate note.
Click Replace.
Do I need client consent to get notes from dictated or written summaries?
Great question! The answer is usually yes, you do need consent to get notes from dictated and written summaries, but please see this article for exceptions.