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Exposure hierarchies, SUDS ratings, ABC data, parent coaching — behavioral work generates dense, structured notes. Medical Scribe captures the session while you run it, so the data lands in the chart instead of on sticky notes.
A real example of the documentation Medical Scribe generates for behavioral therapists — ready before your patient leaves the room.
24M with OCD, contamination subtype — session 7 of ERP. Completed 5 of 7 assigned home exposures; touched public door handles without washing on 4 occasions. Home-practice SUDS peaked at 55, down from 80 at baseline. Sleep improved.
Consistent between- and within-session habituation. Y-BOCS 24 at intake; re-administration planned session 8. On track toward goal of SUDS ≤ 50 across hierarchy items 1–6.
Continue weekly ERP; advance to hierarchy item 7 (public transit surfaces) next session. Re-administer Y-BOCS. Coordinate with prescriber regarding sertraline 150mg stability during the exposure phase.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
Coaching a client through an exposure or reinforcing a target behavior takes your full attention. There's no spare hand for charting when the intervention is happening in real time.
Antecedents, behaviors, consequences, trial counts, SUDS ratings, habituation curves — behavioral notes demand a level of granularity that free-text memory at 6 p.m. can't reproduce.
Payers approve continued behavioral treatment based on defined target behaviors, baselines, and session-by-session movement. Vague progress notes are how authorizations get denied.
Real-time transcription that understands medical terminology and clinical context.
Recognizes terms, conditions, and procedures specific to your practice area.
Generate comprehensive clinical notes in minutes instead of hours.
Enterprise-grade encryption and security to protect sensitive data.
These aren't generic formats — they ship in the product today, structured around how you actually document.
Plus 280+ templates across every specialty — or build your own in minutes.
Whether it’s an ERP session, habit-reversal training, or parent coaching, Medical Scribe records the encounter — in clinic, at home, or over telehealth — and drafts a structured note from what happened: the exposures completed, the ratings called out, the client’s response, and the homework assigned.
The built-in Behaviour Therapist’s Note template goes beyond Subjective, Objective, Assessment, and Plan with dedicated Interventions and Evaluation sections — the exact technique used, the client’s measured response, and progress against treatment goals. The Psychotherapy Note template adds Mental Status Examination and Risk Assessment when the case calls for it.
Continued authorization for behavioral treatment depends on documented, measurable change. Because Medical Scribe records the actual data from each session — baselines, ratings, habituation, goal progress — and never invents findings, your notes show the trajectory reviewers are looking for, in your own clinical words.
Yes — any measurement spoken during the session (a SUDS check, a frequency count, an antecedent-behavior-consequence sequence you narrate) is placed in the Objective section of the note. It records only what was actually said; it never estimates or fills in data.
The generated note is a progress note for the clinical record — interventions, measurable response, plan. Your private process notes remain separate and yours, and you review and sign every note before it's finalized.
Yes. Medical Scribe records in-person and telehealth sessions on iOS, Android, Web, Apple Watch, and Mac, so a clinic exposure session, a home visit, and a video parent-coaching session all produce the same structured note.
The built-in Behaviour Therapist's Note template (Subjective, Objective, Assessment, Plan, Interventions, Evaluation), plus the Psychotherapy Note and Mental Health Note for fuller clinical records with MSE and risk assessment. SOAP, DAP, and custom formats are all supported.
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