Setup

Documentation Rules

Turn each AI summary, draft and audit feature on or off, set the AI note audit budget, choose how patients consent to AI and when visits may be finalized, decide which documents clinicians read across disciplines and credentials, and set each discipline's signing deadline, the checks notes pass before signing and the AI narrative's context questions.

Open Setup > Documentation Rules. The AI features, visit finalizing and sharing panels at the top apply to the whole clinic; below them, pick a discipline. Each discipline starts from its module's defaults, marked Default, until you save your own. Changing the rules needs the Setup: Clinical Manage permission.

AI features#

Each AI feature has its own switch. A feature that is off disappears from every screen, and the app refuses it even if someone tries it another way. The drafting features start on; the summaries start off until you turn them on. Note dictation and Read aloud run on each user's own computer, so they come with every plan, whether or not it includes the assistant; they cost nothing and start on.

Switch	What it does
Patient brief	The patient brief card on the chart's Overview.
Pre-visit brief	The pre-visit brief on My Day and in a saved appointment.
Visit summary	The visit summary of a signed note, and its family version.
Intake and records summary	The intake and records summary on the chart's Documents.
Note drafting	The AI button that drafts the AI narrative of a note.
Progress report and discharge summary drafts	The AI button on long sections of evaluations, progress reports, re-evaluations, recertifications, plans and discharge summaries.
Monthly summary drafts	The AI button on the sections of a monthly summary.
Note text actions	The wand button that rewrites, shortens, expands or fixes the grammar of selected note text. Starts off.
AI note audits	Your AI guideline audit rules: the author's Check Note on a draft and the AI audit after signing. Starts off.
Note dictation	The microphone button that turns speech into note text on the user's own computer. Audio and text are never sent anywhere and use no credits. A plain tool for the clinician's own voice, so it works for every patient, including one who opted out of AI or a visit marked No AI. Starts on.
Ambient session notes	The ambient session panel on a draft: record the session, transcribed on the user's own computer, then draft the note's text fields from the transcript. Audio never leaves the computer; the transcript is sent only to draft and is not kept. Uses credits and needs the patient's audio consent. Starts off.
Patient feedback insights	The AI insights panel on Patient feedback, which summarizes the period's survey answers with names and contact details removed. Uses credits. Starts off.
Caregiver feedback insights	ABA only. The Caregiver feedback insights card on a learner's Caregiver guidance: tone, follow-up and themes from the completed caregiver feedback forms. Uses credits. Starts off.
Read aloud	The speaker button on note fields and Listen on AI summaries, which read text aloud with a voice that runs on the user's own computer, for every patient. Starts on.

While AI note audits is on, two more fields appear:

Field	What it does
Audit budget (% of credits)	The share of each billing period's credits AI note audits may spend (25 percent unless you change it), so audits never use up the assistant. An audit past the budget or the balance does not run.
When an audit cannot run	Allow the note through (the default) or Send the note to QA. Either way signing is never blocked and the note is audited again overnight.

Below the switches:

Field	What it does
AI consent	Clinic-level consent with patient opt-out (the default): your privacy notice and intake forms tell patients about AI, and AI drafts, summaries, briefs and the assistant run for every patient who has not opted out. Patient consent required: they run only for a patient whose AI documentation consent covers drafting from structured notes.
AI disclosure (optional)	Your clinic's own wording about AI for its privacy notice and intake forms, so everyone uses the same text. Its help shows a suggested wording you can adapt. Some states require telling patients when AI is used in their care; check with your counsel.

Click Save AI Settings to apply them. Whatever you choose:

AI runs on clinic-level consent by default.
A patient who opted out, and a visit marked No AI, get no AI drafts, summaries or briefs, no assistant and no ambient session recording.
Recording a session always needs the patient's AI documentation consent.
Note dictation and Read aloud are plain tools that run on the user's computer: they work for every patient.

Every AI feature uses assistant credits. Turning the assistant off turns every AI feature off with it.

Visit finalizing#

Finalize visits applies to the whole clinic and every discipline. It sets the earliest moment a visit started from an appointment can be signed, which is also when it finalizes and its charges reach billing:

Choice	What it does
Any time (the default)	The note can be signed as soon as it is ready
After the scheduled start	Signing waits until the appointment's scheduled start time
After the scheduled end	Signing waits until the appointment's scheduled end time

Signing too early shows why and what to wait for. Visits recorded without an appointment are never held. Click Save Visit Rule to apply it.

Sharing across disciplines applies to the whole clinic. It decides which documents and chart files a clinician on the patient's care team reads when their role sees only their caseload. Each document kind (evaluation, re-evaluation, daily note, progress report, plan of care, recertification, behavior intervention plan, discharge summary, monthly summary, patient form, incident report) and each document category has two settings:

Setting	What it does
Shared across disciplines (the default)	Everyone on the care team reads it, whatever their discipline.
Own discipline only	Only care team members for the document's discipline read it. A chart file takes the discipline of the note or visit it is attached to, else that of whoever uploaded it; a file with neither counts as shared.
Read by	The credential types a clinician must hold, not expired, to read it. Leave it empty (Every credential) to let every credential read it.

Disciplines kept to their own team makes every document and file of the disciplines you pick own discipline only, whatever the rows above say; for example, a mental health team keeping its records apart.

Some people always read every document: owners, administrators and anyone else whose role sees every chart, the author, the provider the document is for, whoever it is waiting on to co-sign or sign, and their supervisors. A chart opened with emergency access shows everything. Staff with no provider profile follow their role as before. Private psychotherapy notes stay with their author whatever you choose. The rules cover the chart's documents and files, the Documentation page, searches and previews, PDFs, AI summaries and drafts, the assistant and reports; demographics, the schedule, billing and the family portal are not affected.

For example, behavior technicians and therapy assistants can read daily notes but not evaluations, plans of care or behavior plans: set Read by on those kinds to your licensed credentials only. Click Save Sharing to apply it. Every change is kept in the audit log.

Signing deadline#

Setting	What it does
Notes have a deadline	Off, visit notes have no deadline.
Due within, Counted in	Hours after the session, days after the session, or a weekday of the next week.
Due soon from	How many hours before the deadline a draft shows Due soon and its author gets a reminder.
Skip weekends, Skip clinic holidays	Leave these days out of the count. Holidays come from your practice.
Lock overdue notes	The author can no longer edit or sign an overdue note until a supervisor grants more time.
More time lasts	How long a grant keeps a locked note open.
Hold charges of late notes	Charges of a visit wait in charge review while its documentation is overdue, and after a late signature until a biller releases them.
Late entry after	A note signed more days than this after its date of service is marked Late entry (7 unless you change it).
Review due within	Days after the author signs that a note review is due.

Other deadlines and overrides#

Below the signing deadline, Other deadlines and overrides lists the discipline's other deadlines. Click Add Deadline to add one:

Due	What has to happen by the deadline
Note signed	The author signs the note. Pick an appointment type, a payer or both to give those visits a different deadline than the one above.
Note co-signed	The supervisor co-signs a note that needs a co-signature.
Caregiver signed	The patient or caregiver signs: the visit attestation the payer asks for, or a caregiver signature block on the note.
Visit completed	The visit is finished: its note signed and, when needed, co-signed.

Every deadline counts from the end of the session, the same way as the signing deadline. When several deadlines fit a visit, the most specific one applies: the one naming both its appointment type and payer, then its appointment type, then its payer, then the discipline's own. Turn off Has a deadline on an override to exempt those visits. Only note signed deadlines can lock a note; any deadline can hold charges while it is overdue.

See Signing deadlines for how authors and supervisors work with them.

Note checks and AI narrative#