Made for Clinical Psychologists
Quality-Check a Clinical Note Before Signing
Also useful for: Therapists, people in Healthcare
Review a draft clinical note against a focused sign-off checklist, then get a prioritized list of corrections, questions, and final checks. The review stays grounded in what was documented and never invents clinical facts or makes an independent diagnosis.
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Use this when
Use this after drafting an intake, assessment, progress, consultation, or discharge note and before signing it. It is especially helpful when the session was complex, risk was discussed, several interventions were used, or you adapted text from an earlier note.
You'll need
- Note type
- Draft note
- Documentation requirements
- Known facts
- Reference material
- Review depth
You'll get
- Every critical and important finding reviewed
- Supported errors corrected
- Unresolved facts verified against appropriate sources
- Required fields checked
- Your explanation of how the note supports its statements
- Your explanation of how the note handles documented risk
By the end of this playbook
You will have:
- Every critical and important finding reviewed
- Supported errors corrected
- Unresolved facts verified against appropriate sources
- Required fields checked
- Your explanation of how the note supports its statements
- Your explanation of how the note handles documented risk
Sample
This is sample data, not your prompt. Pro unlocks this higher-stakes Playbook. On Free Playbooks you can still copy the assembled prompt into any AI.
Sample input
Note type: Progress note Review depth: Full pre-signing review Known facts: The session occurred by secure video. A symptom measure improved from the prior visit. Passive thoughts were discussed, with no reported plan or intent. A coping plan and crisis contacts were reviewed. Follow-up is next week. Draft excerpt: "Client attended in office and continues to worsen. Client denied all safety concerns. Therapist provided CBT. Client was receptive. Continue current plan." Documentation requirements: Identify service format, connect progress language to available evidence, document relevant risk review and response, name interventions, describe the client's response, and state follow-up timing.
Sample assembled prompt
A. Sign-off status Pause and verify. The draft conflicts with the known... It also makes an unsupported deterioration... B. Priority findings 1. Critical before signing - "denied all... Verify the source record and revise... 2. Important - "attended in office":... Correct the service format. 3. Important - "continues to worsen":... Clarify which evidence supports the statement... 4. Important - "provided CBT": The... Name the documented technique without adding... 5. Important - "was receptive": The... Replace it only with an observed... 6. Important - "Continue current plan":... C. Coverage checklist Accuracy: Needs revision -... Observable support: Needs verification - Worsening... Risk documentation: Needs revision - The... Interventions: Needs revision - The intervention... Client response: Needs revision - The... Follow-up: Needs revision - Timing is... D. Safe edit suggestions Suggested wording -... Questions only I can resolve -... - Which specific intervention was used? - What did the client say... - Is there evidence supporting worsening,... F. Final sign-off check [ ] Correct...