You can keep clinical notes directly in Saltroad using the Clinical Notes feature.
You can create rich-text notes, with a searchable history so you can quickly find a customer's previous notes.
Finding a client's notes: use the Referral dropdown on the Clinical Notes page to see all the notes for one client, newest first. You can also click the referral reference on a client's card in your Caseload to go straight to their notes.
Every note is linked to a session, an intro call or a referral, so your notes live alongside the relevant client and piece of work rather than in a separate system.
To create a new note:
Click the “+ New note” button on the Clinical Notes page
Choose what the note is for: Service sessions, Intro calls or Incidental (see below)
Pick the session (eg. session 3 from a block of 6), the intro call, or the referral the note relates to
Type up your notes (changes are saved automatically)
Find, open and edit all notes from the main Clinical Notes page
Types of note:
Service sessions: notes for a session your client has paid for.
Intro calls: notes for an intro call that has taken place. The note is named "Intro Call with [client name]", which you can change.
Incidental: notes that aren't tied to a session, such as a call with a school or another professional. You set the date and time it happened.
IPA symbols: click IPA in the note toolbar to open a tray of phonetic symbols, then click a symbol to add it to your note. Quick keys add /…/ and […] around the text you've selected.
Attachments: click Attach files on a session or intro call note to add documents and images, such as reports or photos of work. You can attach PDF, Word, JPEG, PNG or HEIC files, up to 20 MB each and up to 20 per note, and open, download or remove them from the note.
And a few important things to highlight:
Clinical notes must be added to every session before you can mark it as delivered. Empty notes don't count. If a session has no notes, you'll see: "Clinical Notes Not Logged: You must log your session notes before marking this session as delivered."
Notes can't be added once a session has been marked as delivered, so add them first.
Service extras, such as travel costs, don't need clinical notes.
If there is an Appointment booked for a session, this date pulls through as the session date to the note, but can be changed if needed
Within a note, you can do some basic text formatting, download a PDF version or copy and paste the text to other docs as needed.
Your notes are stored securely in our encrypted database, and are not shared with customers or other therapists. If you use AI-Assisted Notes to transcribe a session, the audio is processed by the Saltroad Assistant in order to draft your note, and may be used to improve our AI models where the customer has separately consented to that (see the AI-Assisted Notes article).
Saltroad requires that all therapists meet the record keeping standards set out by the HCPC. These cover keeping clear, accurate and contemporaneous records, storing them securely, and retaining them for the appropriate period.
See the HCPC guidance for full details: https://www.hcpc-uk.org/standards/meeting-our-standards/record-keeping
Check out our new AI-powered clinical notes feature.