Form labels for AI-generated charting notes

AI Scribe creates clinical documentation by analyzing your session transcripts and filling in form fields based on the field labels you provide. The quality and accuracy of AI-generated notes depends directly on how specific and clear your field labels are as prompts for the AI system.

This guide provides practical strategies for writing field labels that produce better clinical documentation, with specific considerations for trauma-informed care and PTSD treatment.

Summary

• Use clear, specific language that matches your clinical documentation needs
• Include terminology preferences and professional standards
• Focus on observable, client-reported, or clinically assessed information
• Avoid labels that might lead AI to make inappropriate clinical inferences
• Consider the trauma-informed nature of your practice in all label wording
• Remember that AI works best with concrete, actionable instructions rather than general requests

Core Principles

1. Be Specific and Direct

Instead of: "Notes"

Use: "Document specific CBT techniques discussed and patient responses during today's session"

2. Include Terminology Preferences

Instead of: "Patient assessment"

Use: "Client assessment - refer to individual as 'client' and use they/them pronouns unless otherwise documented"

3. Focus on Observable Behaviors

Instead of: "Mental status"

Use: "Clinical observations of client behavior, mood, and cognition explicitly noted by provider during session"

Field-Specific Guidance

Session Content Documentation

Therapy Progress Notes:

"Summarize key therapeutic interventions used today, client responses, and progress toward treatment goals. Focus on evidence-based techniques like CPT components discussed."

Trauma Processing Documentation

"Document specific trauma-related topics addressed, client's expressed thoughts about the trauma, and any cognitive restructuring work completed during this session."

Homework and Between-Session Activities

"Record any therapeutic homework assignments given, client's completion of previous assignments, and their reported experiences with prescribed activities."

Clinical Assessment Fields

Symptom Documentation

"Document PTSD symptoms explicitly reported by client during today's session. Only include symptoms the client directly described or discussed."

Progress Measurement

"Note client's self-reported changes in PTSD symptoms since last session, using their own words when possible."

Safety Assessment

"Document any safety concerns, risk factors, or protective factors explicitly discussed or observed during this session. Require direct clinical assessment statements."

Administrative and Continuity Fields

Treatment Planning

"Record treatment plan modifications discussed during session and client's expressed agreement or concerns about proposed changes."

Medication and Medical Coordination

"Note any medication-related discussions, side effects reported by client, or coordination needs with other healthcare providers mentioned during session."

Trauma-Informed Considerations

Language and Terminology

• Always specify person-first language: "client with PTSD" not "PTSD client"
• Include instructions for respectful, non-pathologizing language
• Emphasize client agency and strength-based perspectives

Example

"Document client's expressed strengths and coping strategies discussed today. Focus on resilience factors and client's own words about their progress."

Avoiding Inappropriate Inference

Since trauma therapy involves emotional content, be explicit about when AI should avoid making assumptions:

Instead of: "Emotional state during session"

Use: "Client's explicitly stated emotional experiences during session - do not infer emotional states from tone or speech patterns"

Cultural Sensitivity

"Document any cultural, spiritual, or identity factors the client mentioned as relevant to their trauma experience or recovery process."

Common Pitfalls to Avoid

1. Vague Instructions

❌ "General notes about the session"

✅ "Specific therapeutic techniques used and client's verbal responses to each intervention"

2. Leading the AI to Infer

❌ "Client's anxiety level"

✅ "Client's self-reported anxiety symptoms and their described severity using client's own language"

3. Missing Context

❌ "Treatment progress"

✅ "Client's reported progress on trauma processing goals established in previous sessions, including specific examples discussed"

Template Suggestions for Common Fields

Session Opening Documentation

"Document client's presentation at session start, including any updates they provided about their week and current concerns they expressed."

CPT-Specific Documentation

"Record work completed on challenging unhelpful thoughts, including specific thought records discussed and client's insights about trauma-related beliefs."

Session Closing and Planning

"Document session summary provided to client, homework assignments given, and client's questions or concerns about next steps in treatment."

Quality Improvement Tips

1. Start Simple: Begin with basic prompts and refine based on AI output quality
2. Review and Iterate: Regularly assess AI-generated notes for accuracy and adjust labels accordingly
3. Include Examples: When helpful, include brief examples in your labels of the type of information you want captured
4. Test Different Approaches: Try variations of label wording to see what produces the most accurate documentation

By following these guidelines, you can maximize the accuracy and clinical utility of AI-generated documentation while maintaining the therapeutic integrity and trauma-informed approach that defines quality PTSD care.