Write the note and add the diagnosis
Every claim needs a session note and at least one ICD-10 diagnosis behind it. AI Scribe can draft the note for you; adding the diagnosis is the one part that's always yours.
- A session that happened, with its appointment carrying the right Service (lesson 6.2)
- AI Scribe set up with your template, if you'd like the draft written for you (lesson 3.4)
Draft it with AI Scribe
In a Carepatron Telehealth call, the AI sidebar transcribes automatically and drafts the note when the call ends. In person: open the client's record → New note → Start transcribing, then Generate note into your template.
The full workflow is in Lesson 3.4. For claims, one rule matters: read the draft and correct it. This is the record a payer could one day audit, so it needs to be right.
Add the ICD-10 diagnosis
- Open the note and click the DX icon in the toolbar.
- Select the diagnosis, or several. Previous diagnoses and Conditions on the record show up first.
- The codes appear at the bottom of the note.
Where else the diagnosis lives
- On the appointment: View → Billing details also takes diagnosis codes.
- On the client's record: keep long-running diagnoses as Conditions (profile Overview → Conditions), so they're one click away every session. When one stops applying, set it to Inactive.
Tick these off in your own workspace before moving on.
Three routines that keep notes claim-ready.
The practices that never get chased about missing notes tend to run one of these.
AI Scribe drafts during the session, and the note is reviewed and signed before the end of the day. Nothing carries over.
Ongoing diagnoses live as Conditions, so the DX picker surfaces them instantly.
Associates draft the note and add the DX, the supervisor reviews, and only then is it signed and locked.
Does AI Scribe add the diagnosis for me?
No. It drafts the narrative from the transcript, but the diagnosis is a clinical decision, so you add it yourself via the DX icon.
Can a note carry more than one diagnosis?
Yes, select as many as apply. Hover over a DX tag at the bottom of the note to see its description.
What happens if there's no diagnosis?
The claim won't get through validation. Add the DX before signing and it builds cleanly.
Do I have to use AI Scribe?
No, a note you type yourself works exactly the same. AI Scribe just gets you to a reviewable draft faster.