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How to Make Notes

Updated yesterday

Welcome to Wellnite, your comprehensive mental health platform designed to streamline your therapy sessions and ensure accurate note-taking for every client.


Accessing the Notes Section

To begin, log in to the Wellnite Dashboard at wellnite.co.

  1. From the main dashboard, navigate to the Members tab.

  2. Select the client’s name from the member list.

  3. Inside the client’s chart, click on Notes to begin creating or editing documentation.


Types of Notes Available

Within the Notes section, you can choose one of two options for documenting sessions:

1. Manual Notes (Note)

  • Enter your notes directly in the text field provided.

  • All notes should follow the SOAP format:

    • S: Subjective – client’s concerns, symptoms, or complaints.

    • O: Objective – measurable observations, test results, or assessments.

    • A: Assessment – clinician’s analysis and interpretation.

    • P: Plan – treatment approach, next steps, and follow-up actions.

  • Ensure that each SOAP section is filled thoroughly to maintain accurate records.

2. AI-Assisted Notes (Wellnite Note)

  • Select the client’s clinical condition from the dropdown menu.

  • If the condition is not listed, select “Other Clinical Condition.”

  • Add key details about what was discussed during the session.

  • Click Generate Wellnite Notes to produce a draft based on the information provided.

  • Review and edit the AI-assisted draft to confirm accuracy before saving.


Editing Existing Notes

If you need to make changes to an existing note:

  1. In the client’s chart, go to the Notes section.

  2. Locate the note you wish to update.

  3. Click on it to open it for editing.

  4. Save the updated note once edits are complete.


Mandatory Fields for Documentation

For every note, you must fill out the ICD-10 / Diagnosis code field.

  • Select the correct code from the dropdown menu.

  • This step is required to ensure proper documentation and billing compliance.


✅ By following these steps, you can create accurate, compliant, and detailed notes for every session using either manual SOAP entries or Wellnite’s AI-assisted note generation.

If you have any concerns about your notes, kindly contact [email protected] or call (415) 449-7796 for assistance.


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