Clinical notes and documentation

Synalux has two places for notes, and they do different jobs:

• SOAP Notes (the page is titled Clinical SOAP Generator) turns text you dictate or type into a draft laid out as Subjective, Objective, Assessment and Plan. It is a drafting tool. It does not file the draft to a patient's chart.
• Session Notes (the page is titled Session Notes) holds the notes that belong to the chart. A note there is written, submitted for review, approved or returned by a different clinician, optionally co-signed, and finalized.

Sidebar entries come from your practice type's template. In the code's templates an ABA practice labels the SOAP page SOAP Notes and the Session Notes page Note Co-Sign; other practice types label the SOAP page Clinical Notes, Therapy Notes or Exam Notes, and their templates have no sidebar entry for Session Notes. The Session Notes page is at /app/notes.

Draft a SOAP note from dictation

1. Open the SOAP page. Wait until the Loading your workspace… message is gone.
2. Optionally choose a patient in the Select patient… list. The Clone Previous Note and Fetch Latest Session Data buttons stay disabled until a patient is chosen.
3. Put text in the Raw Data / Dictation box by typing, with Fetch Latest Session Data, or with Start Dictation. (Clone Previous Note fills the Clinical Draft panel instead; see below.)
4. Choose a note type in the Template list in the Clinical Draft panel.
5. Select Generate Insurance Note. It clears the Clinical Draft panel, including a cloned note, and writes a new draft from the dictation box, streaming while Generating... is shown.

The draft panel displays the text but is not an editing box. To change a generated draft, copy it out of the panel.

Fetch Latest Session Data

This button replaces whatever is in the dictation box with a block headed [SESSION DATA — patient name]. The block lists the patient's most recent visit from the schedule in the past 12 months (date, length, provider and type): the newest one that has started and was not cancelled, rescheduled, a no-show or only requested. This is schedule information; it does not show that a session note was written. The block also lists up to 15 active goals and the most recent data point for each target. When it finds none of these it says No recent session data on file for this patient. The same message appears when the records could not be loaded (a failed request reads as empty), so it does not prove the patient has no data on file. The block ends with a line asking you to add or dictate your narrative and then generate. Review the block, because it replaces earlier text in the box.

Clone Previous Note

This button puts the patient's most recent session note that has any Subjective, Objective, Assessment or Plan text into the draft panel, with a heading for each section that has text. It looks through that patient's 100 most recent notes. When none of those has SOAP text for the patient, the page says This patient has no previous note with SOAP content to clone. An older note may still exist.

Dictation

• Dictation turns speech into text in your browser. The page shows a message that audio never leaves your device, and the code backs it: audio goes only to a speech model running in a browser worker.
• The speech model is English-only.
• Your browser loads the speech runtime from a public content delivery network, and loads the model through the browser, when dictation starts. Plan on having an internet connection when you start dictation.
• Your browser asks for microphone permission. If it is refused, the page says Microphone access is required. Please enable it in your browser settings and try again.
• Recognized words are added to the end of the text in the box, in chunks of about two seconds of speech. They are not inserted at the cursor. Stop Dictation transcribes the last partial chunk before it stops.
• While dictation is running, recognized speech keeps the idle sign-out timer from firing, within the limit described in Offline saves and device drafts.

Suggestions and the sparkle button in the dictation box

The dictation box is the same text field used elsewhere in the portal. It shows grey word suggestions that you accept with Tab or the right arrow, and it has a sparkle button that corrects spelling and grammar.

• Suggestions: once the box holds at least 5 characters, the field sends its text, plus up to 500 characters of text from the surrounding page, to the Synalux server. The server sends Google's Gemini model the last 200 characters of the box, that page text, and up to three short summaries (150 characters each) of earlier saved work that match words from the end of the box. The server refuses text over 4 KB, so its suggestions stop in a long box; suggestions the field makes on its own from words it has learned (below) continue.
• Accepting a suggestion or a correction also teaches the field for the rest of your visit. Those words are kept only in the open page: they are not saved on the device, and they are forgotten when you sign out. If another account signs in while the page is open, for example in another tab, text help stops and the page reloads, so nothing you typed is sent or suggested under that account.
• Sparkle button: if a language model is running on your own computer, the field tries it first. If none is running, or that attempt fails, it sends the box's text to the Synalux server, which asks a cloud AI model. A local model therefore does not keep the text on your computer.

This is separate from dictation audio, which stays in the browser, and from Generate Insurance Note, which does not use a cloud model. The assessment narrative fields use a different setting: they turn off the cloud suggestions, the learned-word suggestions and the sparkle button. Built-in word suggestions still appear as you type. Instead, a moment after you stop typing, they send the field's text to the Synalux server for a grammar check by the practice's private language model (a model server on a private network address, not the cloud model above).

Template list and note presets

• The list starts on Therapy Session.
• When your practice has note presets, they are listed. Each is labelled with its CPT code and name when it has a code. The list shows shared presets plus your practice's own. Shared presets written for ABA (CPT 97151 to 97158, or the BCBA or RBT role) are hidden from practices of other known specialties: pediatrics, family medicine, dental, mental health, physical therapy, dermatology, veterinary and nutrition.
• When the practice has no presets, the list offers Therapy Session and Progress Note.
• Choosing Therapy Session or Progress Note tells the generator which layout to use. Choosing a practice preset does not: the generator then picks one of its four built-in layouts (Initial Evaluation, Progress Note, Discharge Summary, or Therapy Session for ABA and behavioral wording) from the words in your text.
• A preset can define form fields (checkboxes, single choice, text, longer narrative and a typed-name field). They appear in the draft panel, and Required for sign-off: lists required fields that are still empty. The values you enter are kept with the draft on this device. They are not added to the text sent to the generator, and nothing on this page files them to the chart.

What Generate Insurance Note does

• It needs at least 10 characters of text, and the text can be at most 32 KB. A user can make 30 generation requests a minute.
• The instructions given to the generator say not to make up clinical data, to include only what the dictation states or clearly implies, and to write Not documented in this encounter. for a section with no information. Review the whole draft before you use it.
• The generation service sends your text only to a model server on a local or private-network address. It does not fall back to a cloud model. When that server is not reachable, no draft is produced and the page shows the service's error, for example Local LLM unavailable. Start Ollama or enable cloud PHI processing to continue.
• Restaurant workspaces cannot use the clinical SOAP page.

Keep drafts safe

• The page saves a draft to your browser 3 seconds after you stop changing it. The draft holds the dictation text, the generated note, the chosen template and patient, and any preset field values. It is encrypted with a key that stays in your browser, and it belongs to your account and the current workspace.
• Reopening the SOAP page restores the draft. The editor stays locked until the saved draft has loaded.
• If a saved draft was written under a device key that no longer exists, it cannot be opened. The page removes it and says A draft saved on this device before you last signed out could not be opened, so it was removed. Anything sent to recovery at sign-out is under Saved draft recovery.
• If the browser cannot store the draft, the page says Draft storage is unavailable or unreadable. Keep this page open and preserve your text before leaving.
• At Sign out, and when the idle timer signs you out, open drafts are sent to Saved draft recovery. See Offline saves and device drafts for the details, including what happens when a draft cannot be saved.

Saved draft recovery

The Saved draft recovery section on the SOAP page lists the copies you saved at sign-out in the current workspace. Select Review saved copy on an entry to see its drafts, then Restore this draft. Restore is available only when no note is in progress on the page, and it keeps the saved copy and does not finalize anything. Twenty copies load at a time; use Load more copies for the rest. If the list cannot load, the page says to check your connection and workspace access, and offers Refresh saved copies.

Write a session note

Open Session Notes. The six tiles at the top (All notes, Drafts, Submitted, Returned, Co-signed and Finalized) and the tabs under them (All, Draft, Review Queue, Returned, Co-Signed, Finalized) filter the list. Review Queue and Submitted include notes that are submitted or approved. The search box, Search by client..., matches the client's name. The list loads the 100 most recent notes by session date.

Select New SOAP Note to start one. The button appears only for roles that can author notes. In Note Details:

• Patient is required. The form opens with the first patient in the list already selected, so check it before you write.
• Note Template is optional. A star marks presets that are mapped to the patient's coverage, based on the patient's insurance provider text. Choosing a preset shows its CPT code, role, form type and required fields, and records it with the note. It does not fill the four sections.
• Date is required and starts at today's date. Duration (minutes) starts at 120. Note type offers SOAP Note, Session Note, DAP Note, Narrative Note, Supervision Note, Parent Training Note, Assessment Note, Discharge Summary and Progress Note.
• Subjective, Objective, Assessment and Plan are four text boxes, whatever the note type.
• Link to Treatment Goals is a free-text box for the goals the note relates to.

Save stores the note as a Draft. Select a note in the list to see it. Its author can select Edit while it is a draft or has been returned.

After a session is saved in Sessions

When you select Complete and save session on the Sessions page, a draft session note is created for that session. The completion screen offers Review draft note, which opens the note editor for it. The editor shows a Recorded evidence panel (Responses, Targets, ABC entries, Duration, and a row for each recorded target) beside four boxes: Subjective and participant context, Objective session facts, Assessment and Plan. Only the note's author can edit it, and only while it is a draft or returned. Save draft saves to the server and needs a connection. Changes stay on the page until the server acknowledges the save. Submit the note for review from the Session Notes list.

Review and finalize

A note moves through these statuses: Draft, Submitted, Approved, optionally Co-signed, and Finalized. A reviewer can also return a submitted note, which makes it Returned.

1. The author selects the note and then Submit for Review. A returned note offers Resubmit for review.
2. A reviewer who is not the author selects Approve or Return to author. Return to author opens Return note to author. Enter the Correction requested text (required) and select Return note. The text appears on the note as Reviewer feedback.
3. On an approved note, a reviewer who is not the author can select Co-Sign and then Finalize & Lock, or select Finalize & Lock directly. Co-signing is optional. A co-signed note shows Co-signed by the reviewer's name and the date.
4. Finalize & Lock records who finalized the note and when. A finalized note cannot be changed.

Rules the server enforces:

• Only the author can submit a note, and only while it is a draft or returned.
• The author of a note cannot approve it, return it, co-sign it or finalize it. On a submitted note, Approve and Return to author are disabled for its author, with the message Waiting for a different clinician to review this note.
• Authoring is limited to these roles: owner, admin, practice admin, clinician, BCBA, BCaBA, provider, therapist, supervisor, RBT, clinical director, doctor and medical technician. Reviewing (approve, return, co-sign, finalize) is limited to owner, admin, practice admin, supervisor, clinical director, BCBA and provider.
• Every submit, approve, return, co-sign and finalize action carries the note revision you loaded. When someone has changed the note since, the server refuses with note changed; reload before review. Reload the note and try again.
• These actions are applied by the server. If your connection was down when you selected one, it has not been applied. Check the status badge on the note afterwards.

Requests that read or change session notes are written to the audit log (who, what and when). The log write is best effort, so a failed log write does not block a save.

Related guides

• Offline saves and device drafts
• Report signatures and BoldSign templates: signing is available for reviewed assessments and released FBA/BIP reports. The Session Notes page has its own review and finalize steps and does not send a note for signature.
• Clinical tasks
• Patients