How It Works
You write a template with instructions and examples
The system automatically replaces placeholders (like patient name, age, etc.) before the AI processes the transcript
The AI follows your template structure and generates the note
The AI never sees the raw placeholder variables. By the time it processes your template, all placeholders have already been swapped with real values.
Placeholders
These are automatically replaced by the system before processing. Use them anywhere in your template.
Placeholder | What It Becomes | Notes |
| Patient's name | Always available |
| Provider's name | Always available |
| Provider profession/taxonomy | Always available |
| Session date (MM/DD/YYYY) | Always available |
| Patient date of birth | Always available |
| Recorded scales/assessments from the encounter | Always available |
| Patient's age | May be |
| Patient's gender/birth sex | May be |
Handling - values: Some placeholders may contain - when patient history isn't available or no patient is linked. Your template instructions should account for this gracefully (e.g., "If [age] is -, omit age from the opening line").
Template Structure
Your template is written in standard markdown. Use headers, bold, bullet points, tables, and horizontal rules to define your note structure. The system handles all the wrapping and processing automatically.
## Section Header
Content and structure here...
Instruction Blocks
Instruction blocks tell the AI how to fill in each section. They are written as HTML comments and are never included in the final note output.
<!--[INSTRUCTIONS]-->
Tells the AI what to do, what to include, and how to handle missing information.
**Chief Complaint:**
<!--[INSTRUCTIONS]
Use the patient's own words in direct quotes.
Must be a negative statement or concern, never a positive statement.
Keep to 1-2 sentences.
-->
<!--[EXAMPLE]-->
Shows the AI a concrete example of what good output looks like for that section.
<!--[EXAMPLE]
**Chief Complaint:** "I'm worried about getting my Adderall filled since
I was out of state. And the stuff with my mom is still bothering me."
-->
You can use both together (and typically should). Instructions define the rules, examples show what following those rules looks like.
Building a Section
Here's the general pattern for any section in your template:
## Section Name
**Field Name:**
<!--[INSTRUCTIONS]
What this field should contain.
How to handle missing information.
Any hard rules (always do X, never do Y).
-->
<!--[EXAMPLE]
**Field Name:** Example of a well-written output for this field.
-->
Tips for Writing Good Instructions
Be specific about defaults. If something isn't mentioned in the transcript, tell the AI exactly what to write (e.g., "If not mentioned, default: Denies headaches or dizziness.")
Be specific about what's required vs. optional. If a section can be omitted when not applicable, say so. If it must always appear, say that too.
Use "never" and "always" deliberately. The AI takes these literally. "Never use positive statements as the chief complaint" means exactly that.
State the format you want. Narrative paragraphs? Bullet points? A table? Tell the AI directly.
Call out common mistakes. If you've seen the AI do something you don't want, add a line like: "Do NOT summarize the transcript directly" or "Avoid generic CBT unless specific techniques are documented."
Tips for Writing Good Examples
Make them realistic. Use examples that look like actual notes from your practice.
Show the format. If you want bullet points with sub-items, your example should have bullet points with sub-items.
Show edge cases when helpful. An
<!--[EXAMPLE TO AVOID]-->block can clarify what you don't want.
Conditional Sections
Some sections should only appear under certain conditions. Handle this in your instructions:
### Scales and Assessments:
<!--[INSTRUCTIONS]
If [scales] contains recorded assessment data, document the results here.
If [scales] is `-` or empty, omit this section entirely.
-->
### Telehealth Documentation:
<!--[INSTRUCTIONS]
Only include this section if the visit was conducted via telehealth.
For in-person visits, include only the line: "In person visit."
-->
Medication Sections
Medications are common across behavioral health notes. Here's a recommended structure:
#### Current Medications:
<!--[INSTRUCTIONS]
List all current medications with doses.
Note any changes, titrations, additions, or discontinuations.
For controlled substances, always document safe use expectations.
-->
- **<!-- Brand name (Generic name) strength formulation -->**
- **Sig:** <!-- Dose, frequency, timing, route -->
- **Changes:** <!-- Changes made today or "No changes made today" -->
- **Adherence:** <!-- Adherence status and barriers -->
- **Side Effects:** <!-- Adverse effects or "No side effects reported" -->
- **Comments:** <!-- Optional: clinical rationale, pharmacy coordination -->
The <!-- --> comment placeholders inside the bullet structure show the AI the format you expect. It will replace them with real content from the transcript.
Tables
Use standard markdown table syntax. Tables work well for structured data like history, diagnostic codes, and review of systems:
| ICD-10 Code | Diagnosis |
| :--- | :--- |
| F90.0 | Attention deficit hyperactivity disorder, predominantly inattentive type |
| F33.1 | Major depressive disorder, recurrent, in partial remission |
Common Patterns
Required in Every Note
If a section must always appear regardless of transcript content, state it clearly:
<!--[INSTRUCTIONS]
ALWAYS include this section in every note regardless of risk level.
-->
Handling Missing Information
Be explicit about what to do when something isn't discussed:
<!--[INSTRUCTIONS]
Use "not reported" or "denies" rather than N/A.
If not mentioned in the transcript, default: "Denies significant pain."
-->
Enforcing Consistency Across Sections
If two sections need to match (e.g., diagnoses in the Assessment must match the Plan), say so:
<!--[INSTRUCTIONS]
The diagnoses listed here MUST match the diagnoses referenced in the
Plan section. Do not invent or assume diagnoses not supported by the transcript.
-->
Starter Template
Here's a minimal template to get started. Add, remove, or modify sections to match your documentation needs:
## Subjective:
**Chief Complaint:**
<!--[INSTRUCTIONS]
Use [patient_name]'s own words in direct quotes when available.
Must be a negative statement, concern, or reason for the visit.
Never use positive statements like "doing great" as the chief complaint.
Keep to 1-2 sentences.
-->
<!--[EXAMPLE]
**Chief Complaint:** "I've been feeling really anxious and I can't sleep."
-->
**HPI:**
<!--[INSTRUCTIONS]
Summarize the patient's history chronologically in narrative paragraph form.
Include symptom onset, evolution, duration, and triggering events.
Cover mood, sleep, appetite, energy, and functional impact.
Note treatment response and medication side effects if applicable.
Do not use bullet points.
-->
<!--[EXAMPLE]
**HPI:** [patient_name] presents for follow-up management of generalized
anxiety disorder. Since the last visit two weeks ago, she reports persistent
difficulty falling asleep, typically lying awake for 1-2 hours before sleep
onset. Daytime anxiety has been moderate, with frequent worry about work
performance. She notes mild improvement in appetite since starting her
current medication but continues to experience intermittent tension
headaches. Energy levels remain low, impacting her ability to maintain
her exercise routine. She denies any side effects from her current
medications and reports taking them as prescribed.
-->
---
### Medications:
#### Current Medications:
<!--[INSTRUCTIONS]
List all current medications with doses.
Note any changes, titrations, additions, or discontinuations with rationale.
If no medications are prescribed or patient declines, state:
"Medications were considered and determined not needed at this visit."
Never say "no medications were discussed."
-->
- **<!-- Brand name (Generic name) strength formulation -->**
- **Sig:** <!-- Dose, frequency, timing, route -->
- **Changes:** <!-- Changes made today or "No changes made today" -->
- **Adherence:** <!-- Adherence status and barriers -->
- **Side Effects:** <!-- Adverse effects or "No side effects reported" -->
- **Comments:** <!-- Optional: clinical rationale, pharmacy notes -->
<!--[EXAMPLE]
- **Lexapro (Escitalopram) 10mg tablet**
- **Sig:** 10mg once daily in the morning, PO
- **Changes:** No changes made today. Continue current regimen.
- **Adherence:** Good adherence, taking daily without missed doses.
- **Side Effects:** No side effects reported.
- **Trazodone 50mg tablet**
- **Sig:** 50mg at bedtime as needed for insomnia, PO
- **Changes:** Increased from 25mg to 50mg due to continued sleep
onset difficulty.
- **Adherence:** Fair adherence, uses 3-4 nights per week.
- **Side Effects:** Mild morning grogginess reported, resolves
within 30 minutes of waking.
- **Comments:** Patient counseled on allowing 7-8 hours for sleep
when taking trazodone to minimize residual sedation.
-->
#### Discontinued Medications:
<!--[INSTRUCTIONS]
Document medications discontinued within the past year or relevant
to current presentation. If none, write: "None reported"
-->
<!--[EXAMPLE]
- **Buspirone (BuSpar) 10mg tablet**
- **Discontinued:** October 2025
- **Reason:** Insufficient anxiolytic response after 8-week trial
- **Duration:** 2 months (August 2025 - October 2025)
-->
---
## Objective:
##### Mental Status Examination:
<!--[INSTRUCTIONS]
Document observations from the clinical encounter for all domains.
If specific findings are not mentioned in the transcript, use clinically
appropriate defaults indicating normal findings.
Always explicitly document presence or absence of suicidal and
homicidal ideation in Thought Content.
-->
- **Appearance:** <!-- Grooming, hygiene, dress. Default: Well groomed, dressed appropriately. -->
- **Behavior:** <!-- Cooperation, engagement, eye contact. Default: Cooperative, engaged, appropriate eye contact. -->
- **Speech:** <!-- Rate, rhythm, volume. Default: Normal rate, rhythm, and volume. -->
- **Mood:** <!-- Patient's own words in quotes. Default: Reports mood as euthymic. -->
- **Affect:** <!-- Range, congruence, reactivity. Default: Euthymic, full range, congruent with stated mood. -->
- **Thought Process:** <!-- Organization, flow. Default: Linear, logical, goal directed. -->
- **Thought Content:** <!-- SI/HI, delusions. Default: No suicidal or homicidal ideation. No delusions. -->
- **Cognition:** <!-- Attention, concentration, memory. Default: Intact attention, concentration, and memory. -->
- **Insight:** <!-- Poor, limited, fair, or good. Default: Good. -->
- **Judgment:** <!-- Poor, limited, fair, or good. Default: Good. -->
<!--[EXAMPLE]
- **Appearance:** Well groomed, casual attire appropriate for the setting.
- **Behavior:** Cooperative and engaged throughout. Good eye contact.
- **Speech:** Normal rate, rhythm, and volume.
- **Mood:** "Anxious but a little better than last time."
- **Affect:** Mildly anxious, reactive, congruent with stated mood.
- **Thought Process:** Linear, logical, goal directed.
- **Thought Content:** No suicidal or homicidal ideation. No delusions.
- **Cognition:** Intact attention, concentration, and memory.
- **Insight:** Good.
- **Judgment:** Good.
-->
---
## Assessment:
<!--[INSTRUCTIONS]
Provide a clinical summary integrating findings from the visit.
Detail presenting symptoms, relevant history, and diagnostic impressions.
Write in narrative paragraph form.
-->
<!--[EXAMPLE]
[patient_name] is a 34-year-old female with generalized anxiety disorder
presenting for follow-up. Anxiety symptoms remain moderate with primary
impact on sleep and occupational functioning. Current SSRI regimen is
partially effective with room for optimization. No safety concerns are
present. She demonstrates good insight and treatment engagement.
-->
##### Diagnostic Codes:
<!--[INSTRUCTIONS]
List each diagnosis with its ICD-10 code.
Primary psychiatric diagnosis first.
Only include diagnoses supported by the transcript.
-->
<!--[EXAMPLE]
- F41.1 - Generalized Anxiety Disorder
- G47.00 - Insomnia, unspecified
-->
---
## Plan:
<!--[INSTRUCTIONS]
Organize by each diagnosis addressed during the visit.
Diagnoses here must match those listed in Diagnostic Codes.
For each, include medication management, therapy, labs, referrals,
and follow-up timing as applicable.
Use numbered format with diagnosis name and ICD-10 code.
-->
<!--[EXAMPLE]
1. Generalized Anxiety Disorder (F41.1)
Continue Lexapro 10mg daily. If anxiety symptoms do not improve
over the next 4 weeks, will consider increasing to 15mg. Continue
supportive psychotherapy focused on cognitive restructuring and
relaxation techniques.
2. Insomnia (G47.00)
Increase trazodone from 25mg to 50mg at bedtime as needed. Reviewed
sleep hygiene strategies including consistent wake time, limiting
screen use before bed, and avoiding caffeine after noon. Reassess
sleep quality at next visit.
3. Follow up
Return in 4 weeks for medication reassessment and continued therapy.
-->
Quick Reference
Element | Syntax | Purpose |
Instructions |
| Rules the AI follows for each section |
Examples |
| Shows the AI what good output looks like |
Anti-examples |
| Shows the AI what NOT to do |
Placeholders |
| Auto-replaced by the system before processing |
Inline field hints |
| Shows the AI the expected format for a field |
Markdown headers |
| Structures note sections |
Horizontal rules |
| Visual section separators |
FAQs
Can I use any markdown formatting? Yes. Headers, bold, italics, bullet points, numbered lists, tables, and horizontal rules all work.
What happens if I don't include an instruction block for a section? The AI will still attempt to fill the section based on the transcript, but without specific guidance it may not format or prioritize content the way you prefer.
Can I have multiple examples for one section? Yes. You can include multiple <!--[EXAMPLE]--> blocks or put multiple examples inside a single block, labeled clearly (e.g., "EXAMPLE 1:", "EXAMPLE 2:").
Do I need both instructions AND examples? No, but using both produces the best results. Instructions set the rules, examples show what following those rules looks like in practice.
Can I make a section conditional? Yes. State the condition in your instructions (e.g., "Only include this section if the visit was conducted via telehealth").
How do I handle placeholders that might be -? Add handling instructions like: "If [age] is -, omit age from the opening line" or "If [scales] is -, omit this section entirely."
Is there a length limit for templates? Templates should be as long as they need to be to produce accurate notes, but excessively long templates with redundant instructions may reduce output quality. Be concise and specific.