An AI medical scribe for psychiatry
A psychiatric assessment is long, personal and full of detail that matters later: what the patient said, how they said it, and how you judged the risk. ClearPass transcribes the conversation once the patient has agreed and drafts an English note for you to review, so your attention can stay on the person in front of you.
What a psychiatry note has to hold
A first assessment and a medication review look different, but they are read later for the same things: was the history complete, was the mental state examined and described, was risk assessed, and is the plan clear enough for the next clinician to follow.
- Presenting complaint in the patient's own words, then the timeline: onset, triggers, sleep, appetite, energy, concentration, and what has changed since the last visit.
- Past psychiatric history: earlier episodes, admissions, self-harm, treatments tried and how well each worked.
- Substance use with amounts, frequency and last use, not just 'occasional'.
- Social circumstances: housing, work or study, relationships, dependants, supports.
- Mental state examination: appearance and behaviour, speech, mood (subjective) and affect (objective), thought form and content, perception, cognition, insight and judgement.
- Risk to self, to others and from others, with protective factors and your overall formulation.
- Rating scales you used, such as PHQ-9 or GAD-7, with the score and the comparison to last time.
- Medication: current dose, adherence, side effects, and monitoring such as drug levels or metabolic bloods where they apply.
Much of the mental state examination is observed rather than spoken. A transcript cannot see a restricted affect or psychomotor slowing. Say your observations aloud once the patient has left, or type them in, and they will reach the note.
Consent and sensitive content
Each time you tap Transcribe, ClearPass asks you to confirm the patient has agreed. In psychiatry that question deserves a real conversation: explain that the visit is transcribed to write your note, that the audio is discarded, and that the patient can decline or ask you to stop at any point. If they decline, type or dictate a summary afterwards. The note tools work the same way with typed input.
Some content goes beyond the usual sensitivity: disclosures of abuse, information about third parties, legal matters. You decide what belongs in the clinical note. The Ask box takes plain instructions such as 'remove the details about the brother and keep only that there is family conflict', and the draft is rewritten without them.
For a longer read on how to explain transcription to patients, see patient consent for AI scribes.
Example: medication follow-up
S: Woman in her thirties, 6 weeks on sertraline 50 mg for a moderate depressive episode. Mood 'a bit better, maybe 5 out of 10'. Sleeping 6 hours, early waking twice a week. Appetite returning. Nausea in the first 2 weeks, now settled. No alcohol since last visit. PHQ-9 today 12 (19 at last visit). O: Casually dressed, good eye contact, calm. Speech normal rate and volume. Affect mildly restricted, reactive. Thought form coherent, no delusional content. No perceptual abnormalities. Oriented. Insight good. Risk: Passive thoughts of not waking up in the past fortnight, less often than before. No plan, no intent, no preparatory acts. No self-harm. Protective factors: two children, supportive sister, engaged with care. No risk to others identified. Overall risk judged low. A: Moderate depressive episode, partial response. P: Sertraline increased to 100 mg daily. Safety plan reviewed and crisis contacts given. Continue weekly therapy. Review in 4 weeks, sooner if worse.
Structures that fit psychiatric work
There is no guided template group for psychiatry. The Family Medicine / GP group has a Mental health (anxiety / depression) case, and Emergency / Critical Care has Acute psychiatric / behavioural, which suit primary care and acute presentations. Most psychiatric notes are best written from free text with one of the note structures.
New patient suits a first assessment, Follow-up suits medication reviews, and Full headings gives nine sections for a thorough workup. If your service documents therapy sessions in a format such as DAP or BIRP, that is not built in: set it up once with My own structure by typing the headings you use, and reuse it. Detailed length keeps every clinical fact said, which suits first assessments; Concise suits brief reviews.
Letters after a psychiatry visit
- Referral letter to psychology, a community team, or a physician for physical health monitoring. See the referral letter template.
- Sick note when the illness affects work, written from the same visit. See the sick note template.
- Medical report for an employer or a legal process, where the patient has consented to its release. See the medical report template.
- Patient instructions in plain language: the dose change, side effects to watch for, and what to do in a crisis.
- A prior authorization letter when a plan requires approval for a long-acting injectable or a newer medicine.
Reviewing the draft
- Read the risk section word by word. It should state your judgement, not only summarise the conversation. Make sure no denial has been flipped and nothing the patient said about risk has been left out.
- Check quotations. If you keep the patient's own words in the note, confirm they are quoted accurately and are ones you want in the chart.
- Check doses and scores. The Numbers check marks any number in the note that was never said in the transcript, which catches a wrong dose or a misheard score.
- Remove what does not belong. Third-party detail and anything the patient asked you to keep out can be removed with one instruction in the Ask box.
More on this in how to review an AI note.
What ClearPass does not do
- It does not replace your judgement. Every note is an AI draft that you review and correct before it is used.
- It is not a medical device and does not make clinical decisions. It is a documentation aid.
- It does not connect to your EMR. The note is copy-ready text that pastes into any system.
Privacy
Clinical note content is not stored on ClearPass servers: it is processed to write the note, then discarded. Consultation audio is transcribed and discarded, never stored. Your note history stays in your browser, on your device, and you choose how long it is kept. Common identifiers are removed from typed and transcribed text before it reaches the AI; that is a best-effort safeguard, so leave names, ID numbers and file numbers out where you can. Processing goes through the AI providers named in our Privacy Policy, which sets out exactly what each one receives and how long it keeps it. ClearPass does not sign HIPAA business associate agreements today.
Questions
Can a patient refuse to have the session transcribed?
Yes. ClearPass asks you to confirm consent every time you start. If the patient says no, do the visit as usual and type or dictate your summary afterwards; the note structures, letters and Ask box all work from typed text.
Does it write psychotherapy note formats?
No psychotherapy formats are built in. You can create your own headings, for example Data, Assessment, Plan, with My own structure and reuse them. Whether session process notes are kept separately from the clinical note is a matter for your service's policy.
Will it capture what I observe but do not say?
No. It writes from what was said or typed. Speak your mental state observations aloud after the patient leaves, or add them by typing, before you generate the note.
What does ClearPass cost?
The 7-day trial is free, needs no card and simply ends after 7 days, with no automatic charge. After that there is one plan: $78 a month or $858 a year, with every visit transcribed.
Try it on your next clinic day
The full product for 7 days, with no card and no automatic charge. Then $78 a month or $858 a year. Pricing details.
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