Check the context.
Confirm that the target, activity, and session context match what occurred. Verify the record and date inside your clinical system.
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Your judgment stays in the note
A thoughtful check before sign-off.
A concise review aid for a draft clinical note. Use your setting’s documentation requirements and your professional judgment; a checklist cannot establish clinical or billing compliance.
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Separate observation from interpretation.
Check that examples and measurements accurately reflect the session. Keep clinical interpretation clear and justified.
Review the support and next step.
Confirm that cueing, participation, and the plan are represented accurately. Edit anything that overstates certainty or omits meaningful context.
Make it your record.
Resolve errors and gaps before signing. AI-generated drafts still require your review, correction, and professional sign-off.
Make it useful
A plan you can keep.
Print this sheet or save it as a PDF. Keep personal or clinical details in your own approved records.