If you’ve spent years developing your documentation system, the idea of handing part of it to an AI tool, like Jane’s AI Scribe, might give you pause. For therapists and mental health professionals, compliant therapy notes are more than a workflow. They’re a professional protection strategy that helps keep you in line with your regulatory requirements.

The importance of excellent documentation

Liane Wood, a registered psychotherapist and CEO of Build Your Private Practice, understands this well. She spent more than two decades in professional liability insurance before becoming a therapist, so she knew from experience what’s at stake when documentation falls short. “It’s your documentation that either saves you or doesn’t,” she said.

That history is part of what made her slow to adopt AI Scribe when it first launched. Not because she feared technology, but because she had already built a note system that worked for her. The question wasn’t whether she needed better notes. She already had those. The question was whether AI Scribe could meet her compliance standards, while helping her move quickly.

It took her about two weeks to find out that it could.

Liane had been using AI Scribe for a couple of weeks when a very busy stretch appeared on her calendar: a keynote speech, an event, a summit, all alongside the usual expectations of her practice. In the midst of this, Liane unexpectedly lost two family members.

Great notes, less cognitive load

Liane, a strong compartmentalizer, can stay focused during her sessions, no matter what else is going on around her. But historically, post-session is when she has found it harder to focus. “When I’m not in front of a client and I have major things going on in my life, that’s when my personal world is going to consume my thoughts,” she explains. “And so I know from past experience that that is the time that my notes get behind.”

This time around, because she’d just started using AI Scribe, Liane was able to complete her notes and keep her practice moving. Because she didn’t have to reconstruct the session from scratch, Liane could review and edit a note post-session, signing off without the historical cognitive load she’d experienced.

Here’s how, even if a little by accident, Liane set herself up to maintain her standards, create strong documentation more efficiently, and manage a challenging time.

Tip: If recording isn’t a fit for your practice, you can use Jane’s AI Scribe to dictate. Use AI Scribe after a session by speaking aloud about what happened, the tool generates a draft note from your dictation, and you decide what to keep.

Liane’s AI Scribe setup advice

For mental health practitioners, a default SOAP note format doesn’t necessarily reflect how many therapists actually document. And, like with any tool, if your desired output doesn’t fit your template, it can create more work, not less.

What Liane discovered is that a good prompting system can change this entirely. Rather than using a pre-built format, you can write your own instructions for each section of your chart template. Jane’s AI Scribe responds to what you tell it to look for.

Her risk assessment section is a good example. She needed that field to capture some specific things, for example, any mention of suicidality, self-harm, or related risk factors, plus what she did in response. She wrote a prompt, targeted specifically at that, for that section of her chart. AI Scribe listened for those signals across the full session transcript and populated only that section, with only that content.

The result of one strong prompt with one clear purpose, was exactly the output Liane was looking for.

How to write prompts that actually work

The quality of your AI Scribe output depends almost entirely on the quality of your instructions. Here’s some advice from Liane:

• Write a separate prompt for each section of your chart template. Don’t ask one prompt to do everything. Specificity is what keeps irrelevant content out.
• Tell AI Scribe exactly what to look for and, just as importantly, what to ignore. Liane’s risk assessment prompt was built to surface only risk-relevant content.
• Use AI to help write your prompts. Liane used ChatGPT to draft her AI Scribe prompts, then tested them against real sessions and iterated. You don’t have to write perfect instructions from scratch.
• Expect a short ramp-up period. Liane spent roughly two weeks refining her prompts before they were producing consistent, usable output.

Tip: for a closer look at how other disciplines are using Jane’s AI Scribe, check out this Clinical notes and AI: how practitioners across disciplines are using Jane’s AI Scribe.

On compliance: what to ask before you start

When evaluating any AI Scribe tool, here are some questions to ask before you jump in:

• Is the tool compliant with HIPAA or PIPEDA?
• Can recordings and transcripts be permanently deleted?
• Is patient data ever used to train AI models?
• What documentation is provided to support your own consent workflows?
• Where the data is stored and processed?

These are questions a good vendor should be able to answer without hesitation, and the ones worth having answered before you hit record for the first time.

Is it time for a new system?

If you’ve built a documentation system you trust, that’s not a reason to avoid AI Scribe. It might actually be the best reason to try it. Liane didn’t come to AI Scribe because her notes were a mess. She came to it because she had a clear picture of what good, compliant documentation looked like for her practice, and that made her an excellent editor of the output.

AI Scribe didn’t replace her system. It just took the parts that required effort and made them a little faster, so that during a challenging time, her notes stayed current and her standards stayed intact.

If you’re already using Jane, and would like to give AI Scribe a try, you can set it up directly in your account. Here’s how to get started.

And if you’re new to Jane, welcome! We’re glad you found your way here. If you’d like to book a demo our team would be happy to show you around.

FAQ

Is Jane’s AI Scribe HIPAA compliant?

Yes, Jane’s AI Scribe is both HIPAA and PIPEDA compliant.

Does AI Scribe only produce SOAP notes?

No. You can write custom prompts for each section of your chart template. The output format is determined by your instructions, not a fixed template.

Can I create separate prompts for different sections of my template?

Yes. This is one of the most useful features for mental health practitioners. Each chart section can have its own prompt with its own instructions about what to capture and what to leave out.

Do I need client consent to use AI Scribe?

It depends how you use it. If you’re recording or transcribing a live session, informed and documented consent is required. If you’re dictating after the session (so, no client audio recorded), you may not need consent, but you should still ensure your use complies with the legal and regulatory obligations outlined by your regulatory body (including transparency to clients where needed).

How long does it take to get AI Scribe working the way I want it to?

Liane had her prompts producing consistent output in about two weeks. Expect a short testing and refinement period, especially if you have a detailed or structured chart template.

Note: AI Scribe is available to customers in Canada and the US.