Creating and Managing Client Session Notes

In this article:

• Creating Notes
• Adding Sections
  • Image Annotation
• Attaching Bookings, Documents, Protocols, and Tasks
• Updating your Progress
• Sharing Notes with Clients
• Signing Notes
  • Supervisor Signatures
• Duplicating Notes
• Adding Quick Notes
• Accessing previous notes while creating new notes

Creating Notes

You have complete flexibility in how you create notes in Practice Better. Notes can be standalone documents for general client observations, or they can be linked to specific appointments to keep your session documentation organized.

1. Open your client’s record and go to the Notes & Recordings section.
   
   
    
2. Click the Fast Action Button (the red plus icon) in the bottom-right corner and select Add notes.
   
    
3. Alternatively, from either your client’s list of bookings or from My Schedule > My Bookings, click Add notes from the session in the bookings list.
   

📍 Note: You can create notes with or without linking them to a booking. Standalone notes are perfect for general observations, follow-up documentation, or any charting that isn't tied to a specific appointment.

Understanding the Save Options

When working on your notes, you'll see three save options in the top-right corner:

• Save notes: Saves your progress and keeps you on the current page so you can continue working.
• Save and exit: Saves your work and returns you to the client's Notes History page.
• Sign and save: Signs the note (making it read-only and completed), generates a PDF copy, and saves your work. Once a note is signed, it becomes permanently locked and cannot be edited or have its sharing settings changed.

Managing Note Dates

Practice Better tracks two important dates for each note:

• Session date: The date of the appointment or session (if the note is linked to a booking, this date matches the booking and cannot be changed in the note)
• Date prepared: The date you created or finalized the note

You can edit these dates through the note's settings. For notes not linked to bookings, you have full control over both date fields, which is helpful when backdating documentation or preparing notes after a session.

Adding Sections

Text sections allow you to add rich, free-form information to your notes and templates. The text editor gives you powerful formatting options to create professional, detailed documentation.

By default, each note contains one text section to start, and you can add as many additional sections as you need, either from the Fast Action Button in the bottom right, or from the toolbar on the right.

The text editor allows you to embed:

• Images
• Videos
• Links
• Tables
• Lists
• Text Snippets

Adding Form-Style Elements

Using the toolbox on the right side of the editor, you can incorporate interactive form-style elements into your notes, including:

• Checkboxes
• Yes/No options
• Multiple-choice selections
• Rating scales
• Tables
• Image annotations

To add a new section, click the Fast Action Button in the bottom-right corner and select Add section. You can also use the toolbox icons to add specific element types directly.

🪄 AI-Powered Documentation: With our AI Charting Assistant add-on, you can use real-time dictation to capture your notes hands-free, allowing you to focus on your client while the system transcribes your observations. 

Learn more about Practice Better's AI Charting Assistant - AI Dictation →

Maximizing Your Workspace

To maximize your writing area and minimize distractions, click the Fullscreen button in the top-left corner of the notes editor. This expands the editor to fill your screen, giving you more room to work with complex notes or lengthy documentation.

Image Annotation

The Image Annotation tool allows you to add visual documentation to your notes with markup capabilities. This is particularly useful for body diagrams, anatomical references, pain mapping, or any visual assessment that benefits from annotation.

1. Click the Image Annotation icon in the toolbox.
   
    
2. In the pop-up window, choose one of our default image templates (such as body diagrams or facial maps) or upload your own image to annotate.
   
   
    
3. Once the image has been added, use the toolbar above the image to draw, add text notes, create shapes, or add measurements to the image.
   

This feature is perfect for documenting physical assessments, tracking progress visually, or creating clear visual references for both you and your clients.

Attaching Bookings, Documents, Protocols, and Tasks

Notes become even more powerful when you connect them to other elements in your client's care journey. Use the tabs in the Note navigation bar or the Fast Action Button to create meaningful associations that keep all related information connected.

You can link the following resources to a Note:

• Session bookings – Connect your documentation to the specific appointment
• Protocols – Associate treatment plans or care protocols
• Documents – Attach relevant forms, lab results, or reference materials
• Labs – Link laboratory results or diagnostic reports
• Tasks – Create action items for you or your client
• Files – Upload a document of 120 MB or less. Files uploaded directly to Notes will also be saved in your Practice Better Client Documents.

After linking a note to a session booking, you'll see the booking information appear at the top of the note, including the session name and date/time. You can remove this connection at any time by clicking the More Options menu (3 dots) > Unlink Booking.

📍 Note: Each note can only be attached to one booking at a time. If you need to document multiple sessions, create separate notes for each appointment to maintain clear, organized records.

Adding Insurance Codes

For practitioners who bill insurance or need to track diagnosis and procedure codes, the Fast Action Button includes an Add insurance codes option. This allows you to attach relevant diagnosis codes (ICD codes) and procedure codes (CPT codes) directly to your session notes, streamlining your billing and compliance documentation.

Updating your Progress

Practice Better helps you track which notes are complete and which still need attention. When you create a new note, it is automatically set to In progress status, making it easy to identify notes that require additional work.

Understanding Note Status

There are a handful of possible statuses for session Notes, and you can quickly identify each one from the visual indicator on each note in your client record’s list of Notes. 

• In Progress: A circle with two-thirds of the pie filled.
• Completed: Circular star with a checkmark.
• Shared: A globe beside the word “Shared.”
• Signed (read-only): A feather quill.

Changing Note Status

You can update the status to Completed (or back to In progress) by:

1. Going to your client's Notes & Recordings page.
    
2. Clicking the More Options menu (3 dots) next to the note.
    
3. Selecting Mark as completed or Mark as in-progress.
   

✅ Automatic completion: Notes are automatically marked as completed when you sign them, ensuring your finalized documentation is properly tracked.

Sharing Notes with Clients

You have complete control over what information your clients can see in their notes. You can optionally share entire notes or specific sections with clients, creating transparency in your practice while maintaining appropriate professional boundaries.

⚠️ Important: You cannot change sharing settings after you have signed a note. Signing permanently locks the note, including its sharing configuration. Plan your sharing preferences before signing.

What Clients Can See

When notes are shared, clients can view:

• Note summary
• Shared text sections (only the sections you've made visible)
• Attached documents
• Published protocols

Clients cannot add their own notes, comments, or edits to shared notes – this is view-only access that keeps your documentation secure.

How to Share Notes

1. Near the top of your note, select the "Share notes and attached documents with my client" checkbox.
   
    
2. For each text section you want to share, turn on the "Make this section visible to my client" toggle icon (the eye icon) to the left of the section.
   
   
   On smaller devices, you'll see a toggle switch below each section instead.
   

💡 Selective sharing: You have granular control over sharing. If you've checked the main sharing box but haven't made any text sections visible, your client will only have access to the notes summary, attached documents, and published protocols – not the detailed section content.

Accessing Downloaded PDFs

Both you and your clients can download PDF copies of notes:

• Practitioners can download a PDF from the More Options menu (3 dots) next to any note in the client's Notes History page.
  
• Clients can download shared notes as PDFs from their client portal, giving them a permanent record of the information you've shared with them.

Signing Notes

Signing your notes creates a permanent, legally compliant record that cannot be altered. When you sign a note, Practice Better marks it as read-only, which means it cannot be edited, and its sharing settings cannot be changed. This feature is essential for maintaining the integrity of your clinical records.

What Happens When You Sign

Signing a note automatically:

• Makes the note read-only (permanently locked from editing)
• Marks it as completed
• Locks sharing settings (you cannot change what's shared after signing)

How to Sign Notes

1. Create or edit a note.
    
2. Click the Save button in the top-right corner.
    
3. Select Sign and save from the dropdown menu.
   
    
4. If you haven't already added a signature to your account, you'll be prompted to create one.
    

Once saved, you'll notice a signature icon and "Signed (read-only)" label on the note in your client's Notes History page.

⚠️ Important: Signing a note is permanent. Once a note is signed, it cannot be unsigned or edited. This ensures the integrity of your clinical documentation but means you should review your note carefully before signing.

You can view the signed note as a PDF by selecting View as PDF from the More Options menu (3 dots) next to the signature icon on the Notes History page.

Duplicating Notes

Save time by duplicating existing notes rather than starting from scratch. This is particularly useful when you have standardized documentation formats, session templates, or notes with consistent structure that you use across multiple appointments.

1. Go to your client's Notes History page.
    
2. Click the More Options menu (3 dots) next to the note you want to copy.
    
3. Select Duplicate.
   

The duplicated note will appear as a new, unsaved note that you can modify as needed. All sections, formatting, and structure are copied, but the note is not linked to any booking and starts in "In progress" status.

Adding Custom Quick Notes

Custom quick notes provide a fast way to capture brief observations, reminders, or client communications directly from the client record without navigating through the full notes interface.

To create a custom quick note, access the client's Recent Activity page and use the custom notes feature. 

Learn more about creating custom quick notes from the Recent Activity page →

Viewing Recordings While Working With Notes

When your session has been recorded with Practice Better’s AI Charting Assistant, recordings from linked bookings are accessible while working with notes, so you can easily access what was discussed during the session.

Learn more about Practice Better's AI Charting Assistant - AI Summary (telehealth) →

If you've linked a recorded session to your note, the recording will be accessible by clicking View recording at the top of the page:

Clicking this will open a floating pop-up that you can move around your page, close, or collapse. The pop-up contains a play button to listen to the recorded session audio, as well as the transcript, AI summary, and action items.

From here you can:

• Click on an Action Item to create a Task for yourself or for the client. 
• Scroll through and edit the transcript if anything is inaccurate. 
• Save any quotation from the transcript to the recording’s Bookmarks.
• Use the quick-copy button on the AI Summary or any quotation from the transcript to easily add to your Notes. 
• Download the transcript or the audio file from the More Options menu (3 dots) at the bottom of the pop-up.
  

Accessing Previous Notes While Creating New Notes

One of the most valuable features for practitioners is the ability to reference previous documentation while creating new notes. This allows you to maintain continuity of care, track progress over time, and ensure consistency in your documentation.

How to View Previous Notes

While working in a note:

1. Click the client's image/avatar near the top-left corner of the note editor.
    
2. In the pop-up that appears, click the person icon in the top-right corner to open the Client Hub.
   
    
3. Click Notes in the Client Hub to view all previous notes.
   

This workflow keeps your current note open while giving you access to historical documentation, making it easy to reference past sessions, track changes, or copy relevant information forward.

💡 Tip: This feature is especially helpful when documenting progress, comparing assessment results over time, or maintaining consistency in treatment approaches across multiple sessions.

Practice Better's Notes system gives you the professional documentation tools you need while maintaining the flexibility to adapt to your unique practice style. Whether you're creating detailed session notes, sharing treatment summaries with clients, or maintaining compliance records, the platform supports your clinical workflow every step of the way.