AI for Therapy Progress Notes

Progress notes document what happened in a session and why the treatment is justified. Three formats are common. SOAP has four parts: Subjective (what the client reports), Objective (what the clinician observes), Assessment (clinical interpretation) and Plan. DAP combines subjective and objective material into Data, followed by Assessment and Plan. BIRP stands for Behavior, Intervention, Response and Plan, and puts more weight on what the clinician did and how the client responded. There are two main designs. Ambient tools record the session with consent, transcribe it, identify who is speaking and draft the note. Summary tools take the clinician's dictated or typed recap and structure it. Either way, the clinician is responsible for the signed note. A common misconception is that an AI note is just a condensed transcript. A good progress note is selective. It records clinically relevant content, interventions, risk assessment, progress toward goals and the plan. It leaves out most of what was said. Several things should usually stay out of the record: verbatim quotes of deeply sensitive disclosures when a summary is enough, identifying details about third parties, speculation presented as fact, and details of illegal activity or sexual history that are not clinically relevant. The clinician's own working hypotheses and personal reactions also stay out. If kept at all, those belong in separate psychotherapy notes. Progress notes can be read by clients, other clinicians and insurers, and may be subpoenaed. The biggest risk is plausible fabrication. A model trained on many notes may write that a particular technique was used, or that risk was fully assessed, when neither happened. Signing that note creates a false clinical record and possible billing liability, since insurers rely on notes to support medical necessity and the service billed.