AI-assisted notes

Updated

How it works

To use the AI-assisted notes feature: 

  1. During session confirmation, select Fill out template supercharged by AI when selecting note type
  2. You’ll see a screen for you to input a summary of the session, where you can paste in your raw session notes and choose if you’d like to pre-fill relevant sections from the last session’s progress note
    • Raw notes can be notes you took during the session or a summary that you drafted after the session. This can be bullet points, full sentences or quotes from the session. It has to be at least 400 characters long, with details including:
      • Client presentation (symptoms, behaviors)
      • Discussion from during the session (recent events, feelings)
      • Client progress towards treatment goals
      • Clinical interventions used during the session
  3. Once you’ve entered your raw notes, click Generate
    • If you choose to use last session’s note to pre-fill, you’ll then see that all the sections of the SOAP note have been filled
  4. Once you review the AI-populated progress note and make any necessary edits, you can attest and sign the progress note

As a reminder, you should only have one signed note per session in the client record. Attesting and signing the note in Headway will save and store the note to the client record.

Want to try it out? Visit our demo of AI notes.
 

Data and security 

This feature has been designed with privacy and security in mind. Legal, privacy and security policies are in place to ensure that the data involved in the use of this feature is appropriately managed in accordance with applicable data privacy frameworks, including HIPAA.

We partner with Anthropic and use their latest HIPAA compliant Claude Sonnet model to power this feature. We have a zero data retention policy with Anthropic so it doesn't store your session summary anywhere, nor will it use it to retrain the model.
 

How much it costs to use AI-assisted notes

Headway’s AI-assisted notes tool is included at no extra cost - it’s automatically available if you choose to use it.
 

Why we’re launching AI-assisted notes 

We're building AI-powered notes to help you save time on documentation so you can spend more time focusing more on patient care. We know that creating thorough, insurance-compliant progress notes can take time. Our goal is to save time while maintaining high-quality documentation that meets clinical standards and payer requirements.

This feature has been designed with privacy and security in mind. Legal, privacy and security policies and controls are in place to ensure that the data involved in the use of this feature is appropriately managed in accordance with applicable data privacy frameworks, including HIPAA.
 

How to provide feedback

It’s important to always review and edit every AI-generated note draft, and provide feedback on the experience if you have it. To provide feedback, please use the feedback module to let us know how the tool is working, which will appear on the bottom left of the page after you write your note.
 

Talking to your clients about AI use in your practice

You don't need to get consent from patients, since the AI-assisted notes tool only relies on your session summary. However, if you want to have a conversation with your patients, here are some responses we've drafted to common questions your clients might ask.

Why are you using the tool?

“I use an AI-powered note tool to help streamline my documentation and meet the requirements set by insurance companies, so I can focus more on our sessions and less on administrative tasks. It helps me organize my notes efficiently while ensuring accuracy and consistency so your insurance claims can be paid in a timely fashion.”

What information does the tool use?
“This tool takes my written summary of the session and creates a progress note that is compliant with insurance requirements. It does not capture any audio or video recordings of our sessions. It is purely based on my input. I always review and edit everything it generates to make sure it reflects our discussions correctly. This tool helps me spend less time on paperwork and more time providing quality care.”
Are my records secure?
“Headway is trusted with individuals’ most sensitive information, and takes data privacy very seriously. They’ve built a secure data infrastructure and platform, maintain SOC 2 and HIPAA compliance, and follow industry best practices regarding cloud infrastructure and encryption. Headway does not sell your data nor does it share your medical records without first obtaining your consent when required. For more information about Headway’s privacy practices, I encourage you to review Headway’s Privacy Policy and the Notice of Privacy Practices.”
Can I see what the AI writes about my session?

“All of the information included in the AI-generated progress note has been reviewed and confirmed by me. You can always request to see your progress notes as you are entitled to them in accordance with HIPAA.”

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