Notes

Article 02

Reviewing documentation for a CPT code

Documentation Review checks the current note against a primary Current Procedural Terminology (CPT) code. You can also choose an optional add-on code. It shows supported items, details that need attention, and details to confirm.

In this guide, we'll cover:

Checking availability

Running a review

Understanding the results

Reviewing again after editing

Understanding the coding limitation

Checking availability

Documentation Review appears only when it is enabled for your practice. You must also be able to edit the note.

Running a review

Important: The note must contain text before you can run a review.

To run a review:

Open the patient's Notes .

Open an editable note.

Select the checklist icon labeled Review documentation .

Select a Primary CPT code .

Select an Add-on CPT code if needed.

Select Review documentation .

Understanding the results

The results group the checks into Clinical documentation and Code-specific requirements . Each check has one of these labels:

Supported: The note supports the item being checked.

Needs attention: The item may need more information or review.

Confirm detail: A detail needs your confirmation.

Not applicable: The item does not apply.

Open a check to view its explanation, a note excerpt, and a suggested next step.

Important: Nothing from the review is added to the note automatically. Use your clinical judgment to decide whether to update the note and how.

Reviewing again after editing

If you edit the note or change a selected CPT code, PrecisionMind marks the previous results as out of date. Select Review again to update them.

Understanding the coding limitation

Important: The selected codes are used only for the review. They are not billing recommendations. Documentation Review does not choose the correct code, replace coding guidance, or guarantee reimbursement. You are responsible for confirming that the documentation and selected code match the service provided.

Generating Billable Notes

Completing a visit and connecting records

Article 03

Creating AI session summaries and note templates

PrecisionMind can use session audio to create a transcript and a draft clinical note. You can control the note’s structure and writing preferences with note templates.

Obtain patient consent

The patient must consent before a session is transcribed.

Telehealth sessions

When Session Transcription is enabled in Calendar Settings , PrecisionMind asks the patient to choose I Consent or I Do Not Consent before joining.

If the patient declines and later changes their mind, select Start Transcribing . Confirm that you obtained consent before transcription begins.

When Session Transcription is disabled, obtain consent separately. Then select Start Transcribing and confirm consent.

In-person sessions

Obtain the patient’s verbal or written consent. Then select Start Transcribing to begin.

Generate a session summary

In person: Open the patient’s appointment and select Start Recording . Place the device where it can clearly capture both speakers.

Telehealth: Use transcription in the telehealth room. You do not need a separate recording device.

After the session: PrecisionMind processes the session in the background. The summary and draft note usually appear in the patient’s Notes tab within five minutes.

Review: Open Transcripts to review or delete the transcript. Review and edit the note before finalizing it.

Open note templates

Go to Management > Manage Note Templates . You can review existing templates or select Create New Template .

The list shows each template’s name, creation date, default status, and edit action.

Create a note template

To create a template:

Select Create New Template .

Enter a clear template name, such as Standard SOAP, Brief BIRP, or Intake Assessment.

Choose whether to make it the Default .

Add one or more note sections.

For each section, enter a heading and instructions for the AI.

Review the AI settings.

Section settings

Section Heading: The section title, such as Subjective, Objective, Assessment, or Plan.

AI Instructions: What information the section should include and how it should be written.

AI settings

Reference Terminology: Choose how the note refers to you and the person receiving care.

Length: Choose Concise, Default, or Thorough.

Direct Quotes: Choose None, Normal, or More.

System Instructions: Add other writing instructions, such as using objective clinical language or emphasizing measurable progress.

Use and refine a generated note

The selected template controls the note’s sections, terminology, length, use of direct quotes, and other instructions.

After PrecisionMind generates the note, review and edit it. You can also use the AI Assistant to refine individual sections. Changes to the note do not change the original template.

Using features in the telehealth room

Ending a telehealth session

Creating a treatment plan with AI

Creating a manual or blank note

Article 04

Generating Billable Notes

In PrecisionMind, a Billable Note is a structured clinical document specifically engineered to meet the rigorous audit standards of the CPT code you are billing.

While standard AI scribes often miss the nuances of behavioral health, PrecisionMind is purpose-built for the complexities of psychiatry and psychotherapy. As insurance company audits become more intensive, the burden of proof for the level of care provided has never been more important-or more time-consuming. PrecisionMind automates this defensible documentation , protecting your practice while saving you hours of manual entry.

How to Generate a Billable Note

Follow these steps to generate a note that is audit-ready and linked to your billing:

Navigate to the Notes tab and click Create .

Select Category: Choose from Diagnostic Evaluation , Psychotherapy , or Evaluation & Management (E&M) .

Choose Session: Select the specific appointment for the note.

Select Data Sources: Inform the AI by selecting relevant context (e.g., Intake forms, Past Sessions). This ensures the "Golden Thread" is maintained across the patient’s history.

Understanding Billable Notes

Standard AI tools often lack clinical depth. PrecisionMind’s notes are engineered to handle specialized psychiatric data:

Compliance & Medical Necessity: Notes are engineered to meet the strict standards of the specific CPT code you are billing. They automatically frame clinical work to demonstrate the level of care required for reimbursement.

Integrated Medication Management: PrecisionMind pulls current medications from the Patient Profile and e-Prescription records. It cross-references the transcript to document adherence, side effects, and refills.

Longitudinal Clinical Context: Unlike tools that "forget" after a session ends, PrecisionMind pulls relevant data from past sessions and intake forms to create a comprehensive record.

Zero Manual Entry: Once a note is generated, the claim is automatically added to your Unbilled Services with the correct diagnosis and fee.

You can view a sample of an PrecisionMind-generated billable note here: PrecisionMind Sample Note (90792)

Note Generation Options

1. Diagnostic Evaluations (Intake)

Used for initial assessments to establish a clinical baseline.

90791 (PDE, Non-Medical): Focuses on psychiatric assessment.

90792 (PDE, Medical Services): Includes medical components of a psychiatric evaluation.

Workflow: Select Session → Data Sources → CPT Type → Add-ons → Generate Document (takes ~5 mins).

2. Psychotherapy Notes

For ongoing treatment sessions.

Formats: Supports SOAP (Subjective, Objective, Assessment, Plan) or BIRP (Behavior, Intervention, Response, Plan). Available in "Normal" or "Detailed" versions.

CPT Codes: Templates for 90834 (45 min) and 90837 (60+ min).

3. Evaluation & Management (E&M)

For medical management in psychiatric care. Includes a Code Calculator to ensure accurate coding.

New Patients: e.g., 99205 (High Complexity).

Established Patients: e.g., 99213 (Low) or 99214 (Moderate).

Add-ons: Option to attach +90833 for psychotherapy performed during an E&M visit.

Workflow: Select Session → Coding Method (Time vs. Complexity) → Fill required fields → Generate Document .

From Session to Paid: The Workflow

Conduct Session: Use PrecisionMind's HIPAA-compliant telehealth or in-person transcript tool. (A transcript is required for billable notes).

Generate Note: Select the CPT-specific template. PrecisionMind pulls in medications and history automatically.

Approve: Review and sign the generated documentation.

Auto-Bill: The claim appears instantly in your Unbilled Services with the correct diagnosis and fee schedule applied.

Navigating tabs on the Patient Dashboard

Data Sources & Consent

Ending a telehealth session

Understand the patient and client app

Article 05

Creating a manual or blank note

Create a blank note when you want to document care manually instead of using a session transcript.

When to use a blank note

A blank note can be useful when:

The patient did not consent to transcription.

You are documenting care coordination, a phone consultation, or an insurance follow-up.

You need to record an observation or incident outside a scheduled session.

Create a blank note

To create a note:

Select Notes in the left sidebar.

Select the patient.

Select Create Note .

Select Start with a blank note .

Add a SOAP or BIRP structure

To add a built-in structure:

Enter / in the note editor.

Select Generate Template .

Choose a format, such as SOAP or BIRP .

Add your clinical information under each heading.

Create another structure with the AI Assistant

For a different document, ask the AI Assistant to create the headings. For example, enter Create a template for a Psych Intake Evaluation.

Review the generated structure, then add the patient-specific information.

Use note shortcuts

While editing, enter /dx to add the patient’s diagnosis or /rx to add their current medications.

Using features in the telehealth room

Ending a telehealth session

Generating Billable Notes

Generating Billable Notes

Article 06

Saving and signing notes

Save a note while it is still in progress. Sign it when the documentation is complete and accurate.

Save a note

Select Save to keep the note in the patient’s Notes tab. You can return to it and continue editing.

Note: Saving a note does not move it to the insurance billing stage. You must sign the note.

Sign a note

To sign a note:

Select Add Sign .

Type your legal name or draw your signature.

Select the confirmation that says, This note accurately reflects the session and clinical service.

Confirm the signature.

Edit a signed note

A signed note is locked in the patient’s record. If you edit it again, PrecisionMind clears the existing signature. Review the changes and sign the note again to finalize it.

Download a signed note

A signed note includes your credentials and signature date. When you download it as a PDF, each page shows:

Electronically Signed By: [Your Name] | Date Signed: YYYY-MM-DD

Publishing and sending a treatment plan

Sign and complete forms

Article 07

Using PrecisionMind’s AI Assistant

PrecisionMind’s AI Assistant can create draft clinical and administrative documents from information already in the patient’s record.

You can use it to draft:

Treatment summaries.

Letters to psychiatrists or other providers.

Progress reports.

Brief or detailed patient overviews.

Open the AI Assistant

To open the assistant:

Select the patient.

Select Create .

Select Blank Note .

Select AI Assistant .

Generate a draft

To generate a document:

Enter a prompt that explains what you need.

Select Generate .

Review and edit the result before saving or sending it.

Write a useful prompt

Include the document format, intended audience, and level of detail. For example:

Create a summary of this patient’s treatment so far.

Write the summary as a letter to the patient’s psychiatrist.

Include future considerations for the treatment plan.

Important: Review and edit AI-generated content so it reflects your clinical judgment before you use it.