The note is done
when you are.
Subjective, Objective, Assessment, Plan, drafted from the session itself, in your voice, before the client reaches the parking lot. You review, nudge and sign.
Subjective
Reports better sleep this week.
You sign
90837 · F41.1Capabilities
The note, built
while you're present.
Eight ways the draft takes shape during the session, so the work after the work disappears.
Drafted as you talk
Subjective, objective, assessment and plan assemble live, never a blank page at goodbye.
In your phrasing
Medera learns how you write, your openings, your clinical voice, and drafts in it.
Evidence attached
Every line of the note is traceable to the moment in the session it came from.
Any structure
SOAP, DAP, BIRP, intake, discharge, the draft lands in the format the visit calls for.
Golden thread intact
Goals, interventions and response stay connected, the thread auditors look for, kept by default.
Scores woven in
The day's measures land in the note automatically, beside the story that explains them.
Necessity language, placed
Medical-necessity phrasing sits where reviewers look for it, without you thinking about reviewers.
Sign to file
The draft waits for your review and signature. Nothing reaches the chart without it.
The difference
Dictation transcribes.
Medera documents.
Putting your words on a screen still leaves you the writing. A drafted, structured, evidenced note is a different job, done.
Dictation & generic scribes
- You still compose the note, just out loud
- Templates impose their structure on your work
- Lines with no trail back to the session
- Codes bolted on afterwards, if at all
- Sunday evening belongs to the backlog
Medera SOAP notes
- A complete draft waiting at goodbye
- Your structure and voice, learned once
- Every line traceable to its moment
- Codes suggested with the note, evidence attached
- Evenings that belong to you again
Enterprise-grade
Notes that
survive an audit.
A note is a clinical record, a legal document and a claim's foundation. This one is built to hold up as all three.
Signature-gated
No note files without a licensed clinician's review and signature, architecturally enforced.
Version history, complete
Every draft, edit and amendment versioned and attributable to a person.
Evidence for reviewers
Utilization review asks "where's the support?", the note answers with linked evidence.
Supervision-ready
Trainee notes route through supervisor co-signature flows your program defines.
Retention, governed
Org-level retention windows and legal holds, the record keeps itself compliant.
Never trains models
Your notes and your clients' stories never train foundation models.
8 min
median from session end to signed note
100%
of notes signed before filing
Every
edit versioned and attributable
Codes attach themselves
As the note drafts, the right CPT and ICD codes land beside it with the supporting evidence highlighted, clean claims without a coding pass.
- 90837, F41.1, right the first time
- Evidence highlighted for every code
- Denials stop bouncing back
Today's claim
Psychotherapy · 60 min
Generalized anxiety
Brief assessment
Suggested with evidence, right the first time