For clinicians

Skilled note library.

How to write a note, step by step

Choose the visit. Open Note builder and pick A · Initial evaluation or B · Daily visit.
Describe it. Press Speak (or type) and say the pain point or today's summary: side, pain, what you did and for how many minutes, and how the patient responded. Then press Find matches.
Review the suggestions. Check the condition, untick anything that doesn't fit, and press Add selected to note. Nothing to describe yet? Pick the condition and press Start from template instead.
Finish the note. Fill the highlighted blanks and enter minutes for each CPT code; units follow the 8-minute rule. For an initial evaluation, choose the evaluation code. Vary wording keeps visits from reading the same.
Open the ScopeHealth guide. Press ScopeHealth guide →. Fill or untick lines until few fields show "will be flagged".
Record in ScopeHealth. Start recording and read the script aloud, changing words as you go (or use Copy paste-ready text). Transfer the ScopeHealth note to Office Ally with the extension, then review and sign it there. Press Clear everything before the next patient.

Also here: Phrase bank for wording by condition, Shortcuts for a text expander, AI context, and Settings to turn any of these on or off.

Notes and settings stay in this browser only. Don't type patient names, dates of birth or other identifiers here; copy the note into your EHR to finish it.

Reference only. Wording is a starting point for the clinician's own documentation and must reflect what happened at the visit. ICD-10-CM codes were checked against the FY2027 CMS code file. CPT names are plain-language paraphrases, not AMA descriptors (CPT® is a registered trademark of the American Medical Association). Check the current code sets, your Medicare contractor's rules and any payer policy before billing.