Documentation

Checks before signing

The checks a note passes before it can be signed, comparing a note with earlier ones, drafting the narrative with the assistant and bringing back an earlier draft.

Before you sign, NeatPractice checks the saved draft against your clinic's rules. The Before signing section of a draft you can sign lists what it found:

A red item blocks signing. While one shows, Sign is turned off; point at it to read why, for example "Fill in the 4 required fields first".
On the required fields item, Show Field scrolls to the first required field that is still empty and highlights it.
A yellow item is a warning. You can sign, but read it first.
Ready to sign means nothing stands in the way.

The checks run again each time the draft saves. Check Again runs them at once; the section's description says when they last ran ("Checked just now" or "Checked at" a time), and the list briefly highlights when the result changes. If the checks cannot run, the section says so with Retry.

The same checks run again when you click Sign, so a note cannot be signed past a red item.

What is checked#

Check	What it looks for
Required answers	Every required field of the template is filled in.
Restricted phrases	The note uses no word or phrase on your clinic's restricted list. The item names the phrase and what to write instead.
Similarity	The note is not too alike to the patient's earlier signed notes. See Comparing with earlier notes.
Visit checks	The units match what the minutes give, the minutes fit the session and each code's own times, the place of service is where the session took place, and the template is one the codes are documented on. A note with a goal block that marks no plan goal addressed, and gives no reason on a goal, gets a warning.
Audit rules	The note meets your clinic's active audit rules. A rule set to block signing shows red; a user with Clinical: Audit Override can still sign by giving a reason in the sign dialog. Other rules warn.
Note elements	A daily note carries every element your clinic requires, and any visit note every element its payer's note element list asks for. Each missing element shows once. Your clinic's elements and a payer list set to hold signing show red; a payer's other elements warn. ABA session notes check the payer's ABA medical necessity elements instead of its payer list.
AI narrative review	A drafted narrative was reviewed; see The AI narrative.
Provider signature	A code that needs the provider's signature finds your signature image in your profile.
Signing deadline	The note is not locked past its deadline.

Disciplines can add their own checks; ABA session notes also check the medical necessity elements. Whether similarity and visit checks only warn or also block is set per discipline in Documentation Rules.

Rules checked#

Under the items, Rules checked lists every check the note went through and what each answered (Passed, Warning or Blocked), so you can see which rule fired.

Comparing with earlier notes#

NeatPractice compares the note's text with the same patient's earlier signed notes of the same kind, by default your own last 30. Text copied forward from the last note and not edited since is left out. When a note is too alike (90% by default), the similarity item shows the percent and the date of the closest note.

Click Compare to see the two side by side. Words the notes share are marked red; words new in this note are marked green. Describe this session in its own words, save, and check again.

To look for copied notes across the whole clinic, run the Note similarity report.

The AI narrative#

When your clinic's plan includes the assistant, the note's narrative field has an AI button in its toolbar that drafts the narrative for you. The assistant only drafts when you click Draft, never on a visit marked No AI or for a patient who asked for no AI. When your clinic's AI consent is Patient consent required, it also needs an AI documentation consent that covers drafting. Otherwise the panel says why and Draft stays off.

Click AI in the narrative field's toolbar. On a phone or narrow window it opens as a small dialog.
Answer the context questions, such as how the patient presented. The answers are saved with the draft, guide it and never print.
Pick the model under Model: Small, Medium or High. NeatPractice remembers your pick for note drafts, apart from the one you use in the assistant panel, and starts at Medium.
Click Draft. NeatPractice saves the note first, then drafts from the note's answers, the visit's codes and minutes, the goals you marked addressed with what you measured, the activities you logged and your context. On an ABA session note it also uses the session's data: the programs and targets worked with their results, the behaviors and their totals, and the interventions used, even if you have not inserted the data summary.
If the narrative field is empty, the draft fills it. If it already has text, choose Replace or Insert at Cursor. Either way, Undo in the field's toolbar takes the draft back out. Choose Cancel to throw the draft away: the note keeps its text and nothing waits for your review.
Read and edit the text. It is a draft, not a finished note: the field shows Draft, not reviewed beside its label until you confirm.
Open AI again and click I Reviewed and Edited the Draft. Until you do, a note holding a draft cannot be signed.

Drafting uses your clinic's assistant credits at the model you picked, never above your clinic's highest model tier. The draft never claims progress from a single data point and never suggests treatment changes. A draft that fails costs no credits. If drafting fails twice, or the assistant is off or out of credits, write the narrative yourself. If your clinic's plan no longer includes the assistant, the AI button goes away. A draft already in a note still holds signing: click I Reviewed and Edited the Draft beside its item under Before signing.

AI text actions#

When your clinic turns on Note text actions in Documentation Rules, every long text field of a draft has a wand button in its toolbar that edits text you select:

Select the text you want to change in the field.
Click the wand button and pick Rewrite, Shorten, Expand or Fix grammar.
Read the result, marked AI suggestion. Click Apply to put it in place of your selection, or Discard to keep your text. Undo in the field's toolbar takes an applied suggestion back out.

Only the selected text is sent, never the rest of the note or the chart header, and it may not add facts the text does not hold. The same consent and No AI rules as the AI narrative apply, and each suggestion uses your clinic's assistant credits. A field holding an applied suggestion shows AI-assisted beside its label, and applied suggestions appear in AI draft review. Read the whole field again before you sign.

Dictation#

While Note dictation is on in Documentation Rules (every plan has it, and it starts on), every long text field of a draft has a microphone button next to the wand. Dictation understands English.

Click in the field where the words should go.
Click the microphone button. Your browser asks once for permission to use the microphone. While you speak, the field shows Recording and a timer.
Click the button again to stop. The words appear at your cursor (or at the end of the field). Undo in the field's toolbar takes the whole dictation back out in one step.

Speech is turned into text on your own computer: the recording and the text are never sent anywhere, and the recording is discarded as soon as it is transcribed. The first time, your browser downloads the speech model (about 60 MB, or a smaller one on computers with little memory). A ring on the button and a notice in the corner of the screen show the progress, for example "Downloading dictation model, 45% (27 of 60 MB)"; click Cancel on the notice to stop it. The notice says Ready when the model is in, and after that dictation works from your browser's storage. If the download fails, the notice says what went wrong (no connection, a file the download server did not send, or a model that could not start in your browser) and offers Try again, and the button shows a warning you can click to try again. You can download or remove the model ahead of time under Voice models on your profile.

Dictation only turns your own voice into text on your computer, so it is not AI use of the patient's record: it works for every patient, including one who asked for no AI and a visit marked No AI. It needs a current Chrome, Edge, Firefox or Safari. Recordings stop on their own after five minutes; click the button again to continue.

Ambient session notes#

When your clinic turns on Ambient session notes in Documentation Rules, a draft note shows an Ambient session panel above its details. It records the whole session and drafts the note's long text fields from what was said, in the note's own template. It works in every discipline.

At the start of the session, click Record Session. Your browser asks once for permission to use the microphone. While it records, the panel shows a red Recording light and a timer, and the last words heard.
Click Pause for a break and Resume to go on. Discard throws the recording away; nothing is drafted.
At the end, click Finish and Draft. NeatPractice finishes the transcript and drafts the note.
Review the draft. Each field shows the drafted text, which you can edit, and a checkbox to insert it. Click Insert into Note to add the checked fields to the note (below anything already in a field), or Reject Draft and pick a reason, such as Inaccurate or I wrote the note myself. The note then saves like any typing.

The speech is turned into text on your own computer, a short piece at a time, using the same speech model as dictation. The audio never leaves your computer and is discarded as soon as each piece is transcribed. Only the transcript text is sent to draft the note, with the patient's, the provider's and the patient's contacts' names replaced first, and the transcript is not kept afterward. Each draft uses your clinic's assistant credits.

A draft waiting for review holds signing: Sign asks you to insert or reject it first. Read every inserted field again before you sign; you sign what the note says, not what was recorded. Recordings stop on their own after two hours.

Read aloud#

While Read aloud is on (every plan has it, and it starts on), a speaker button next to the microphone reads a draft field aloud: the selected text, or the whole field when nothing is selected. Click it again to stop. The voice runs on your own computer and the text is never sent anywhere. The first use downloads the voice model (about 90 MB), shown as a ring on the button and in a notice with Cancel, then Ready (or what went wrong and Try again if it fails). Read aloud works for every patient, including one who asked for no AI. Choose your voice and speed under Voice models on your profile.

Draft history#

Every time you click Save, NeatPractice keeps a copy of the draft's answers, and it keeps one before a drafted narrative or a restore replaces them. Choose Draft History in the More actions menu to see the copies, newest first, then Restore on the one you want. A copy of the current answers is kept first, so a restore can be undone. A draft keeps its 50 most recent copies.

To see what changed before restoring, choose Compare in a copy's menu. It lists, section by section, each answer that differs between that copy and the draft as it is now (including typing not saved yet), plus any section added, removed or moved. Comparing changes nothing.