Using dictation for client notes

If you don’t want to use Note Taker to record a client session, you can use the dictation tool to verbally capture session information at a later time. In this guide, we'll cover:

• Dictating client notes
• Dictating clients notes with the SimplePractice for Clinicians app
• FAQs

Dictating client notes

Important: If your state requires specific consent for AI-use in client care, you can use the Consent for Use of Artificial Intelligence (AI) Tools in Therapy Service form. To send this form, see Does SimplePractice have a consent form available for the use of AI tools in client care?

You can use dictation to record client information like diagnoses, treatment plans, and other clinical observations instead of typing them. Note Taker will draft a note based on your dictation. This tool converts speech into a draft progress note, not plain text. Your dictation is used to generate a draft of the client's session note.

We’ve created an interactive demo for you to explore how to dictate client notes using Note Taker. To view this demo, see Dictate client notes using Note Taker demo.

Important: Similar to recording a client session, Note Taker won't create or store a dictation recording since the transcript is generated in real time. The transcript of the dictation recording and draft note will be available up to 7 days after the recording occurs or when the note is locked and signed, whichever comes first.

To dictate a client note:

1. Navigate to the appointment page
2. In the upper right corner, click Note Taker
3. Select Start recording

Note: Progress notes and psychotherapy notes are now accessed from a single Note tab within your appointment page. We’re in the process of updating content to reflect this change.

A new window will open to begin recording. If this is your first time using the dictation tool, you’ll have to give permission to access your microphone for the recording.

The recording process will automatically begin.

• To pause the recording, click Pause

• To resume the recording, click Resume
  • A minimum of 1 minute of recording is required to dictate a client note
• To cancel the recording and delete anything up to that point, exit out of the window
  • If you choose to cancel, neither a transcript or draft not will be created
• To complete the recording, click Finish

Note: Once the recording is completed, this window will close automatically. You’ll see this once the note is being drafted.

Once the recording is completed, a transcript of your dictation and a draft note will be created within a few minutes. When ready, a modal will appear to load the draft note. Click Load draft to populate it into the progress note.

Alternatively, you can click Don’t load draft to load the draft note at a later time. If you navigate away from the appointment page, you can find the draft note by clicking Note Taker in the upper right corner. The original draft note and transcript will be available for 7 days after the recording occurred or until the note has been locked and signed, whichever comes sooner.

Before saving the note to the client’s appointment, you must review its contents to make sure it aligns with your professional expertise and style. Sign and lock the note as needed.

Dictating clients notes with the SimplePractice for Clinicians app

You can also dictate client notes using the SimplePractice for Clinicians app.

Important: Similar to recording a client session, the recording of the dictation will be deleted as soon as the transcript is created. The transcript of the dictation recording and draft note will be available up to 7 days after the recording occurs or when the note is locked and signed, whichever comes first.

To dictate a client note on the SimplePractice for Clinicians app:

1. Open the SimplePractice for Clinicians app
   • If you already have the app, make sure that it’s up to date to access all features
2. Navigate to the appointment page
3. Select Add + on iOS or Add Progress Note on Android

4. In the lower right corner, tap Note Taker

5. Select Start recording

A small window will open and Note Taker will begin capturing your dictation.

• To pause, click Pause
  • To resume, click Resume
  • A minimum of 1 minute of recording is required to dictate a client note
• To cancel and delete anything up to that point, exit out of the window by clicking the X in the upper left corner of the small window
  • If you choose to cancel, neither a transcript nor draft note will be created
• To complete the recording, click Finish

Once the recording is completed, a transcript of your dictation and a draft note will be created within a few minutes. When ready, the draft note will automatically appear in the Note Taker slideout. Tap Copy note to copy and then paste it into the progress note.

The original draft note and transcript will be available for 7 days after the recording occurred or until the note has been locked and signed, whichever comes sooner.

Before saving the note to the client’s appointment, you must review its contents to make sure it aligns with your professional expertise and style. Sign and lock the note as needed.

FAQs

• If I receive an error message after using Note Taker, can I use dictation instead?
• Is there a recording minimum for dictating a client note?
• Can I use both Note Taker during a session and Note Taker to dictate the client note?
• I used Note Taker to dictate a client note. Can I delete it and re-record it?

If I receive an error message after using Note Taker, can I use dictation instead?

Yes, you can use dictation instead if you received an error after using Note Taker for a session. For more information, see Dictating client notes.

Is there a recording minimum for dictating a client note?

A minimum of 1 minute of recording is required to dictate a client note.

Can I use both Note Taker during a session and Note Taker to dictate the client note?

No, at this time, Note Taker can only be used during a session or to dictate the client note — but not both in a single session. 

I used Note Taker to dictate a client note. Can I delete it and re-record it?

No, at this time, the dictation tool can only be used once. Rather than re-recording, you can edit and revise the draft note before saving it to the client’s chart. For more information, see Dictating client notes.

Additionally, instead of manually changing the content or formatting, you can provide instructions to refine the note and generate an updated version. For more information, see Refining a draft note using instructions.