Module 02 · Clinical Documentation
Notes that write themselves — you still sign every word
SOAP, DAP, and BIRP templates, built-in outcome measures, and AI-assisted drafting with TherapyFuel. Spend session time with the client, not typing after they leave.
Templates that speak clinical language
Choose SOAP, DAP, or BIRP formats out of the box, or build your own template with the structured fields your practice requires. Each format prompts for the specific clinical content that framework expects, so notes stay consistent across every provider in the practice.
- Pre-built templates for individual, couples, family, and group sessions
- Required-field enforcement so notes can't be signed incomplete
- Custom templates for specialty programs (EMDR, DBT, and more)
Template library
TherapyFuel: AI-assisted drafting, human-controlled signing
TherapyFuel analyzes the structure and duration of a session — never audio you haven't consented to record — and proposes a clinically-worded draft note in your chosen format. You edit, refine, and sign. Nothing enters the permanent record without your approval.
- Draft ready within minutes of a telehealth session ending
- Adapts to your phrasing and documentation habits over time
- Every AI-generated draft is logged in a full audit trail
Outcome measures built in
Also included
The full clinical record, in one chart
Standardized outcome measures
PHQ-9, GAD-7, PCL-5, and more — scored automatically and charted across every session for progress tracking.
Treatment plans
Goals, objectives, and interventions linked directly to progress notes so medical necessity is documented clearly.
E-signatures & co-signing
Supervisors and associates can route notes for co-signature before they're finalized in the chart.
Late-note tracking
Dashboards flag notes approaching your compliance deadline before they become a documentation gap.
Chart-wide search
Search across a client's full history — notes, assessments, and treatment plans — in seconds.
Records requests & releases
Generate compliant records packets for client or third-party requests with a full disclosure log.