This guide covers how to document your sessions — from taking notes during a session to generating AI-assisted summaries with Scribe, signing notes, and customizing templates.
In this article:
1. Taking notes during a session
A floating notes panel is available during any active session:
Type directly into the panel — notes auto-save every few seconds.
Use rich text formatting (bold, italic, headings, lists).
Drag and drop files (JPEG, PNG, PDF, HEIC) to attach images or documents.
If transcription is active, you can append transcribed text to your notes.
2. Note formats
Oasys supports five structured note formats:
Progress Note — a general 6-section format covering session overview, interventions, response, and plan.
SOAP — Subjective, Objective, Assessment, Plan.
DAP — Data, Assessment, Plan.
BIRP — Behavior, Intervention, Response, Plan.
GIRP — Goals, Intervention, Response, Plan.
Your default format is set in Settings → Clinical → Note Templates. You can switch formats on a per-session basis.
3. Using Scribe (AI-generated notes)
Scribe generates a structured clinical note from your session. The process starts when you save a session.
Step 1: Save the session
When you're done with a session, click the Save button. This opens the Session Settings dialog — where you give Scribe the context it needs to generate your note.
Step 2: Configure Scribe preferences
The Session Settings dialog includes:
Note template — choose which format to use (SOAP, DAP, BIRP, GIRP, Progress Note, or a custom template).
Therapeutic modalities — select the approaches used during the session (e.g., CBT, DBT, EMDR, IFS). You can select multiple.
Additional instructions — free-text guidance for the AI, e.g., "Focus on the second half of the session" or "Emphasize the client's progress with exposure exercises."
💡 These preferences tell Scribe how to write the note. They're separate from the note content itself — the actual content comes from your session transcript and any notes you took during the session.
Step 3: Save preferences for this client (optional)
Check "Save these preferences for future sessions with this client" to store your selections. Next time you save a session with the same client, Scribe will pre-fill the modalities and instructions automatically. You can always change them per session.
Step 4: Optionally add a risk assessment or mental status exam
The dialog also lets you add a Risk Assessment or Mental Status Exam. This is optional and separate from the AI-generated note.
Step 5: Save and generate
Click Save Session. Scribe generates the note using your transcript, session notes, and the preferences you set. The session is marked as completed.
Editing and regenerating
After saving, the session shows a Needs Review badge. You can:
Open the session to review the AI-generated note.
Edit the content directly if anything needs adjustment.
Regenerate the note if the output doesn't capture the session well.
4. Session analysis
Oasys can generate an AI analysis of each session, including:
Overview summary of what was discussed
Key topics covered
Clinical insights and patterns
Action items for follow-up
Suggested follow-up points for the next session
Presenting symptoms identified
This appears in the Session Analysis tab after the session ends.
5. Signing and locking notes
Once your note is finalized:
Click Sign and Lock.
Confirm in the dialog. This permanently locks the note — it cannot be edited after signing.
The session transcript (if any) is automatically deleted.
⚠️ If you're under supervision, you'll see Submit for Review instead. Your supervisor reviews the note and may request revisions before it's finalized.
6. Customizing note templates
If you're an independent therapist (or your practice allows template customization):
Go to Settings → Clinical → Note Templates.
You'll see the five preset formats. You can create custom templates with your own sections.
Configure AI settings (what Scribe generates) and PDF layout settings for each template.
Set a default template that's used for all new sessions.
You can also upload your practice logo to appear on exported note PDFs.
7. Dictation
During or after a session, you can use voice dictation:
Click the dictation (microphone) button in the note editor.
Speak your notes — they're transcribed to text in real time.
Dictated text is appended to your note with a timestamp.
Frequently asked questions
Are sessions recorded?
No. Oasys uses live transcription (not recording). Transcripts are temporary and permanently deleted once you sign the note.
Can I change the note format after generating?
You can edit the content freely after Scribe generates it. To regenerate in a different format, change the template in the Session Settings and click Regenerate.
What if Scribe doesn't capture the session well?
Click Regenerate to try again, or edit the note directly. You can also add additional instructions to guide Scribe more specifically.
Can I unlock a signed note?
No. Once signed and locked, notes are permanent. Make sure you're satisfied before signing.
Do my clients see my notes?
No. Session notes are only visible to you and your supervisor (if applicable).