Know what to ask. Document what matters.

Start with the visit's central workflow. Choose a Quick Interview for a focused encounter or a Full Interview for a complete evaluation. Move through the presenting concern, history, risk, substance use, and function in a clear clinical order instead of starting from a blank note.

Turn on prompts that explain why a question matters and what to listen for. It can support newer clinicians or clinicians working in a less familiar area. Experienced clinicians can leave it off for a faster workflow.

Based on what you documented, the app may surface possible considerations, missing information, rule-outs, next questions, and safety prompts. It does not diagnose. You decide what applies and confirm the final diagnosis.

Build and review the plan by problem, including medication decisions, therapy, monitoring, safety planning, follow-up interval, and patient instructions.

Review how the documented complexity relates to the level of service you are considering and where the note may need clarification. The software does not determine billability. You choose and verify every code.

Check whether core documentation elements are present with clear statuses: Needs attention, Review recommended, or Core elements documented. Documentation Review does not determine billability.

Output the same encounter as a full narrative or a tight, readable summary, depending on the setting and who reads your notes.

Initial Psychiatric Evaluation, Follow-Up and Medication Management, E/M with Psychotherapy, Individual Therapy, Group Therapy, Facility Rounds, Injection and LAI visits, Cognitive workflows, BHI and CoCM, screening tools, and treatment-plan review.

Use the same clinician-controlled encounter structure in the office, a facility, the home, or through telehealth.