AI-assisted SOAP drafting

• Your organisation's AI switch. An administrator can turn AI off for the whole organisation under Settings, AI. It is on unless someone turned it off. When it is off, the panel says drafting is switched off and you write the note as usual.
• The patient AI agreement, where your clinic uses it. If an administrator added the agreement under Forms, the SOAP draft runs only for a patient who signed it and answered yes to AI-assisted notes, and visit recording runs only for a patient who answered yes to audio recording. Those are the only two places it is enforced. It is not checked for the progress report and discharge summary drafts, or for dictating a summary. If your clinic has not added the agreement, nothing is gated by it. See intake and consent forms.
• Who can draft. The note's author (or a documentation supervisor) with Rehab clinical access, on an unsigned note.
• Which notes. Only SOAP visit notes: a Visit note, or an older SOAP note. An initial evaluation, re-evaluation or plan of care has no whole-note SOAP draft; there, the AI action beside each field drafts that section from what you typed - no recording needed. Progress reports and discharge summaries have their own narrative drafts, described below.

Episode → Notes → Clinical documentation → New document → Visit note → Document this visit

1. Open the visit note for the visit you are documenting. The Document this visit panel sits inside the note.
2. Record the visit in Quick Capture: pain, interventions and focuses, measurements, tolerance and goal progress. It saves as you tap. Answer anything listed under Still needed for this note; nothing is filled in for you.
3. Optionally open Type or dictate notes and add brief visit notes, your own assessment and your plan.
4. Resolve anything under Check before you review, for example a missing side, a 0 degrees that may be a placeholder, or a goal with no baseline.
5. Select Draft SOAP note. The button is enabled once something from today is recorded. A draft usually takes under a minute; the button counts the seconds.

Your notes and capture are saved before the request, and the draft is made from what is saved. If you change them afterwards, the panel says the draft is out of date; select Draft again. There is an hourly limit per clinician (30 drafts by default).

Every source is labelled today, standing or earlier visit, and each drafted section lists the sources it rests on under From:. The names below are the ones you see on screen.

Voice. A summary you dictate feeds the draft directly. An in-room recording does not: its transcript reaches the draft only if you add it to your visit notes, where it stays marked as unverified. See voice documentation.

Not read: the patient's name, date of birth, record number, address, payer or any charge amount; outside records and intake form answers; body-map selections you have not confirmed; and free-text comments on findings. The previous visit's values are never copied into today's findings.

What you select reaches the draft as plain sentences carrying the side, unit and assistance level you recorded - for example AROM left knee flexion 105 degrees. or Strength (MMT) left knee extension 4-/5. Range of motion, strength grades, special-test results and assistance levels belong in Objective; pain, complaints and screening answers in Subjective. A finding confirmed today can appear in Objective; one confirmed at an earlier visit appears only in Assessment, with its date.

Discipline matters. The draft writes the four SOAP sections only. The template's discipline and setting sections - for example Daily activities (ADL/IADL) & participation for OT or Swallowing for SLP - are yours to complete. SLP trial sets reach the draft worded with their cue level; check that the drafted sentence keeps it. See the PT, OT and SLP examples.

The model's answer is checked against its sources before you see it. What fails is removed, and the panel tells you how many sentences were removed and why. There are two kinds of check.

The draft appears under the buttons, one card per section:

• A header line: AI draft · model · time · check every line before signing.
• Assessment is tagged draft - confirm.
• Under each section: why anything was removed, any To clarify: questions, and From: with each source's label and date.
• Chart records the draft could use opens the standing and earlier records word for word, so you can check a sentence against its source.

Read each sentence against what happened in the visit. Missing information stays missing: the draft does not invent a value to fill a gap, so add anything it could not know.

Before any draft, the panel lists what Assessment and Plan can rest on and what is missing, each with a question you can answer. A section that comes back blank says Left blank - missing: …. The Baseline and today table shows today's values beside the earlier value (or none recorded) and the goal's baseline and target.

• Correct: insert the section, then edit it in the note like any other text.
• Reject a section: do not insert it. Discard draft hides the whole draft.
• Try again: add what was missing, then select Draft again.
• No AI at all: Build from your selections (no AI) arranges your Quick Capture selections as note text.

1. For an empty section, select Insert. For a section you already wrote in, choose Add below yours or Replace yours.
2. Or select Insert into empty sections to fill only the sections that are still empty.
3. Use Undo insert to take an insertion back.

The insertion is recorded first, and that marks the note AI-assisted. If it cannot be recorded, nothing is inserted and the panel says so. If you typed into an empty section while the insertion was being recorded, your words are kept and the draft is added below them.

Signing an AI-assisted note asks you to confirm this statement, which is recorded word for word with the signature:

This note contains text drafted by AI. I reviewed every AI-drafted section against the patient and this visit, corrected what was wrong, and the signed note is my own clinical documentation.

You sign under your own credentials, exactly as for any note. AI does not sign, diagnose, decide care or send anything. Once a note is signed, drafting no longer applies to it: a change is made with Amend, which needs a reason and keeps the earlier wording. See review, signing and amendments.

On a physical therapy note, Draft assessment with AI writes the assessment the note type calls for. It reads what you typed in the note and what is on record, and covers each part below only where the record supports it. A part with nothing behind it is left out, never filled.

Before any draft:

• A progress report needs an earlier value and a value from today. Without both, no draft is written and you are asked for the missing values.
• When goal status, today's tolerance or home-program performance is not recorded, the draft is still written and leaves them out, and a question beside it asks for them.

Every sentence is then checked against the facts it cites. A sentence is removed when it:

• says something improved, declined or stayed the same without an earlier and a current value;
• uses a change word that disagrees with the numbers - a shorter Timed Up and Go is faster, not a decline;
• uses an earlier value without that value's date;
• states a goal status, tolerance, home-program independence, a prognosis, or a need for (or end of) skilled care that the cited record does not state - including "all goals met" when one is recorded as partially met.

Occupational therapy and speech-language pathology notes keep the general assessment structure in their own vocabulary until their structures have been clinically reviewed. The structures above are drafts awaiting licensed clinician review.

When you open an editable progress report or discharge summary, a draft of its narrative sections is prepared beside the document: Progress toward goals and Reassessment findings, or Course of care and Goals met / outcomes. It uses the reporting period, visit counts, each goal's recorded description, status, baseline, target and date, and the Assessment and Plan of recent signed notes.

• It never says the patient improved, declined or plateaued: only the goal statuses you recorded say that.
• It never drafts updated goals, the plan of care, discharge status or recommendations.
• It does not use the outcome scores your clinicians entered on the episode.
• A section that fails the checks is left blank with the reason. If the whole draft is withheld, the same facts are offered as text from the record (not AI); inserting that does not mark the document AI-assisted.
• Use Insert or Append per section. Once an AI draft has been shown, signing asks for the attestation even if you inserted nothing.

• It has been tested on synthetic visits only. No clinician has yet evaluated draft quality on real visits.
• The instructions and reference checks are written mainly around PT and OT visits. An SLP visit note can be drafted, but SLP drafting has had the least testing; review SLP drafts with particular care.
• It reads about 6,000 characters of typed notes and up to six goals.
• The pick-lists it reads from are drafts pending clinical review, not validated vocabularies.

These are separate from note drafting. Each produces a draft or a read-only summary that a person reviews, writes nothing to the record by itself, and stops when your organisation's AI switch is off.