The clinical record and the note assistant

The clinical record

What the chart holds, and what it refuses to do.

Most practices run a directory, a scheduler and an EHR that have never heard of each other, and the therapist is the integration. Pexido puts the record in the same app as the booking — and makes leaving with it a first-class feature rather than a retention tactic.

Notes in the format you already use

SOAP, DAP, BIRP or free form, stored section by section rather than as one blob. Drafts autosave every few seconds, because a note lost to a closed tab is not an inconvenience. The template is stamped onto the note when you start it, so changing your default later never rewrites what you already wrote.

A signature is an act, not a side effect of saving

Draft, signed, amended. Signing is deliberate and separate, and puts a cryptographic fingerprint on the text — a signed note is never edited. You add an addendum, which is signed and dated in its own right, and the original stays. Voiding records a reason. Nothing is bulk-signed, and no clinical record is ever deleted.

Diagnoses and treatment plans that hold their history

Search diagnoses by wording rather than hunting a code, and the code's official text for that year is stamped on the day you record it — codes get revised, and the record should say what it said then. Plans are versioned and signable, every goal is tied to an active diagnosis and that link is frozen at signature, a new version starts as a copy rather than a blank form, and a review date that has passed shows up rather than waiting to be remembered.

An episode, from intake to discharge

Treatment has a beginning and an end, and the record says so: an episode of care with its own admission, its own course and a discharge summary — rather than a chart that simply stops having new notes in it.

Measurement, and the line it draws

Standard instruments, versioned, sent to the client from their portal on a repeating schedule. The exact wording of the questions as the client saw them is stored with their answers, so a score three years old can still be read properly. Scores and bands are computed, the trend is drawn over time, and crossing a threshold is recorded. Append-only: a recorded score is never altered. No machine writes a clinical interpretation of it — the number and the trend are the output, the judgement is yours.

Private psychotherapy notes, actually separate

Separate table, separate encryption key. No supervisor, receptionist or Pexido administrator can reach them. They appear in your own full export and never in a client's export or an insurance report, and they are never sent to any model. The separation is a legal distinction; implementing it with its own key is our own decision.

Problems, medications, allergies — and the one list with its own lock

A problem list, a medication list and an allergy list, each carried forward rather than retyped into every note. The allergy list has its own permission and its own lock, because it is the entry another clinician reads fastest and trusts most, and the cost of it being wrong is not a paperwork cost.

Collateral contacts, and the history you were given

The school, the physician, the parent, the clinician before you — recorded as what they are, with what was discussed and on whose authority. Plus the client's own account of their history, kept where it was written instead of being copied into each new note until nobody knows which version is the one they said.

Letters, referrals, and how the referral ended

Letters are drafted, kept, printed and sent from the record. An outward referral is tracked, including the part most systems drop — what came of it.

A client's request for their record is a deadline, not an errand

The client asks from their own account. The request is logged with the legal deadline that applies to it, and so is the response. Every disclosure is recorded too: what went out, to whom, and on what legal basis — which is the register a client has a right to see.

Supervision and co-signature

A trainee's note waits in "pending co-signature" and is not final until the supervisor signs. The co-signature carries its own fingerprint, valid only alongside the original — so a supervised note can be shown to have been supervised.

The client's own details keep their versions

Change an address, an insurer or an emergency contact and the previous version remains. What the chart said on the day you acted on it is answerable later.

A client can restrict a disclosure, and can ask you to correct the record

A client may ask that something not be disclosed — including to their insurer — and the restriction is recorded against the record rather than remembered by somebody. The claim path reads it: a session under a restriction is not quietly written into a claim file.

They may also ask you to correct an entry. If you decline, the denial is a letter that says the four things a denial has to say, and their disagreement travels with the record from then on rather than sitting in a folder beside it. A signed note still cannot be edited; this is the mechanism that exists instead.

A queue of what is unfinished

One page gathering the unsigned note, the unreturned form, the authorisation running out, the review that is due — and every row is an action rather than a notice. Plus a search across the record, and an access log that answers a client asking who read their chart.

Drafting help lives in its own section

Dictation, listening to a session, and expanding a few typed lines all end in a draft you read and sign — described in full under the note assistant, including the seven rules it is held to.

Coming in, and going out

Arriving is free. So is leaving, and we test that it still works.

The biggest practical reason therapists stay somewhere they dislike is the fear of getting trapped again. Both directions are free here, and the export is the one place we would rather over-engineer than be taken on trust.

Bring the chart you already have

Upload the export from your current system — SimplePractice, TherapyNotes, Sessions Health, an ordinary CSV, or the standard interchange format other records are handed over in — and every row is read with a confidence: certain, needs review, or unreadable. You approve, correct or reject each one in a queue. Every imported record keeps a mark saying where it came from: which system, which file, which row, which interpreter and who reviewed it. No model ever touches an imported record — it is never "completed" or "improved", and there is a test that keeps it that way. Free, always.

Leaving is a button, not a negotiation

One control takes everything: notes, appointments, documents, assessments, diagnoses, plans, payments, and your consent forms with their exact text. Your own note templates and intake forms come out too — elsewhere those are the one thing that never does, and rebuilding them from scratch is what makes leaving expensive. Also available in the standard format other systems read. No form, no reason required, no retention screen on the way out. If that ever gains a step, it is a bug.

Readable without us, years later

The format is published, and inside the package is a manifest with a count and a fingerprint for every file, plus instructions for verifying the signatures on your notes. A format only we can read is a soft lock, and the point of this is that you do not need us.

We rehearse it every month, on your behalf

Once a month, for every therapist who has records, Pexido builds a complete export, verifies the fingerprint of each file, and throws it away. There is also a test that refuses to let any clinical table go missing from an export without a written reason. Without that, an export goes quietly incomplete over six months and somebody finds out on the day they want to leave. Saying "we have an export" is not the same as knowing.

Said plainly, because it decides whether this is for you: the clinical side is built and is being finished under legal review before any real client record is kept in it, in the same way everything else here is described as built rather than launched. Nothing in the record is deleted on a timer — disposal is off by default and every clinical table refuses deletion outright. Nothing obliges you to document in Pexido; if you have an EHR you like, keep it. And nothing here will ever show clinical content in a text message, a push notification or an email.

The note assistant

Three ways to get a note, and one of them never records anybody.

Documentation is the part of the week that follows therapists home. The assistant drafts the note; you read it, change what is wrong, and sign it. What it will not do is a longer list than what it will, and that list is enforced by the build rather than promised in a paragraph.

The hour you have just finished, already drafted

Audio is captured in your own browser and sent for transcription in pieces. The text goes to the model, which rewrites only what was actually said into the template you chose — SOAP, DAP, BIRP or free form. The draft appears on screen and the transcript is deleted at that moment. On a Pexido video session the audio comes from the browser rather than from the video service, which is why it works with headphones on.

Or dictate it yourself. Or type four lines and have them opened out.

A large share of therapists will not record a session, and that has to be a real route rather than a worse one. Dictation is your voice only, so no client consent is involved, and it is free up to fifteen minutes a note. Typing a few lines and having them expanded is free too. Both produce a note in the same templates, through the same signature.

The part of the hour that was not therapy is set aside

Greetings, the weather, "can you hear me?", sorting out a payment. The test is not the topic but whether it is about the client: "it's hot today" is chit-chat, "the heat is stopping me sleeping" is about their sleep and stays. One line under the draft names which categories were set aside — the categories only, never their contents — so a short note reads as a short hour rather than as something missing.

Seven rules, and a build that breaks

Reassurance is cheap. These are tested.

Each of the seven has an automated test behind it. The day somebody writes code that contradicts one, the build fails and the change does not ship. That is a different kind of promise from a sentence on a page, including this page.

Audio is never written to disk. Not temporarily, not encrypted — unless you deliberately choose to keep that hour, which is its own decision with its own consent.
The transcript is deleted as soon as the draft exists.
Nothing reaches the record without a human signature. No assistant output has a path into a chart that doesn't pass through you.
Every adult present consents first — in every state, whatever that state's own rule says. A state rule can only take permission away, never grant it. Signed once, not at the start of every session: what the assistant checks for is a consent in force, and nobody is asked again unless what is done with their words changes.
Private psychotherapy notes are never sent to any model. Separate table, separate encryption key, and a test that keeps it that way.
Withdrawing consent stops it immediately, and only forwards. Mid-session it stops inside the hour and what was heard is deleted. What was already written and signed stays, because those notes were made under a consent that was in force at the time — withdrawal governs the future and removes nothing from the past.
An assistant failure never interrupts the session. The video call carries on; the note is a problem for afterwards.

What it will not produce, at all

No diagnosis. No sentiment or tone analysis. No treatment plan. No suggested intervention. And no risk level — we have read a note from another system that recorded a client's risk as currently low, which means a machine graded it. Safety content here is neither highlighted nor removed; it is left exactly as said, for you to weigh.

Risk assessment: it lays out the evidence, you grade it

The assistant collects what was said about safety during the hour — including what you asked about and the client denied, which is part of the record precisely because it was asked. The grading is yours. A safety plan then gets signed, reaches the client, and records when they received it and when they confirmed they had it.

Ask the record, and see where each sentence came from

Put a question to one client's chart instead of reading back through forty notes. Every sentence of the answer links to the record it came from, and a sentence without a source is not shown at all. If the answer isn't in the chart it says it found nothing. If the chart contradicts itself, you get both sources rather than a tidy average.

A brief before the session

Half a page from that client's own records, so two minutes between appointments is enough to know where you left off. Collation only — no interpretation added on the way through.

Every draft says where it came from

Which model, which version of it, which version of the instructions, and how much of the draft you changed before signing. Kept with the note, so a question about a note from two years ago has an answer. There is also a single switch in the admin panel that stops all of it at once.

Group sessions, without naming anyone

The shared narrative of the hour names nobody. The line describing how one member took part is yours to write — and on Pexido video, where each participant is a separate audio stream, the assistant can draft it because attribution is real rather than guessed. Guessing who spoke from one mixed recording stays switched off: a wrong guess puts a client's words in your mouth.

The administrative half

Five smaller helpers, each switchable off on its own.

Letters and scanned documents

A first draft of an administrative letter, and data pulled out of a document somebody faxed or scanned at you — proposed for your review, never filed on its own.

Translating the administrative text

Forms and explanations rendered for a client who doesn't read English comfortably. The clinical judgement stays in English and stays yours.

Is this note complete?

A check that the sections a payer expects are actually filled in, before a claim goes out. It checks for presence, not quality — it will not tell you whether your writing justifies the code, because that is a clinical judgement and we would be guessing.

The billing code suggestion is not a language model

It is a rule, from the length of the session and whether the client is new or established, and it says so on screen. The final choice is yours, because the claim goes out under your licence.

Risk and safety

What a chart has to do on the worst day.

Most of a record's working life is routine. The part that justifies all of it is the afternoon somebody is not safe, and that is the part built first here. The assistant's share of this — laying out what was said, including what you asked and the client denied, and never grading it — is described under the note assistant. This is what the record itself does.

A safety plan the client is actually holding

Written with them, signed, and delivered to their own account — with the moment they received it and the moment they confirmed it recorded. The crisis numbers are filled in before it goes out rather than left as a line to complete later. We have read a plan from another system with "crisis line — number not provided" printed on it; a blank there is the one blank that is unforgivable.

Your practice's crisis protocol, versioned

What this practice does when somebody is in danger — written once, kept with the practice rather than in somebody's memory, and versioned, so what the protocol said on the day it was followed is answerable afterwards.

A mandated report is held differently from everything else

A report you are legally obliged to make is kept under its own encryption key with stricter access than the rest of the chart. It is not an ordinary note with a sensitive subject, and it is not something a receptionist's permission set should ever be able to reach.

Safety content is never the part that gets left out

The assistant sets aside small talk, and there is one category it is forbidden to treat as small talk. Anything about a client's safety is kept, whatever else was going on in the sentence it arrived in. That is a rule with a test behind it, not an intention.

Measures that cross a line say so

Where you use a standard instrument, crossing its threshold is recorded as an event rather than left to be noticed in a column of numbers. The number and the trend are the output; the judgement stays yours, and no machine writes an interpretation of either.

And the limit, stated

None of this is a monitoring service. Nobody at Pexido is watching a chart for signs of anything, no alert leaves the practice, and there is no out-of-hours anybody. Pexido is a record and a set of tools; the clinical duty is yours, and software that implied otherwise would be doing you harm.

Couples, families and groups

More than one person in the room, and more than one chart it belongs to.

A session with a couple is not one client's session with a guest in it. Most systems make you choose whose chart it goes in and then live with the consequence; this one treats the joint work as its own thing and keeps each person's own record intact underneath.

A couple or a family has a chart of its own

With its own episode, its own plan and its own notes — alongside, not instead of, each member's individual record. Who is in it is recorded, and so is each person's role in it.

A joint note travels only where everybody agreed

A note about a session two people attended reaches the other person's copy only where every adult who was present agreed to that. Where one of them did not, it stays out of their copy — and nothing about the refusal is reported to the other.

A group has capacity, membership and attendance

Who belongs to the group, how many it holds, and who was actually there on the day. Each member gets their own note in their own chart for the session, rather than one note the whole group shares.

The shared account of the session names nobody

The description of what happened in a group is written so that it can sit in anybody's chart — and when a member's own note is signed, any name of three letters or more is refused outright. Described in full under the note assistant, because that is where the refusal happens.

A minor, and a guardian who is informed without being given everything

A guardian can be granted access to a young person's portal, and what that access includes depends on the state. The rules are applied by the system rather than remembered by you, and parts of the record can be held back where the law allows it. Being informed and being handed the whole chart are not the same thing.

Group hours are not capped, and group video is not an upgrade

A room that holds a group is in the base price, with a door for each participant. A cap on group hours is the complaint this market makes about everybody else, and one that landed only on group practitioners would be worse than a cap on everyone.

The client's side of the record

The paperwork happens at their kitchen table, not in your first ten minutes.

Every client has an account already — it is the one they booked from. So the forms, the consents and the work between sessions have somewhere to live that is not an attachment to an email, and you are not the courier.

Consents signed once, and re-asked only when the answer could change

The privacy notice, the treatment consent, the telehealth consent — signed once, from a text-message link if that is easier. Nobody is sent back to a signing screen because somebody improved a sentence. The only thing that asks again is a change to what is actually done with their information, which is the only change their answer could reasonably differ on.

And the permission is read out of the text they signed rather than stored as a switch beside it. A client who signed last year's wording keeps last year's behaviour, exactly as it was described to them, until they sign the new one themselves.

Your intake forms, and questionnaires on a schedule

Build the form you actually use and send it before the first session. Standard measures go out on a repeating schedule if you want them to, and the exact wording of every question as the client saw it is stored with their answer — so a score from three years ago still means something.

Work between sessions

Exercises and homework appear in their account rather than on a photocopy that lives in a coat pocket. What came back comes back to the chart.

Sharing a note on purpose, and knowing it was read

A signed note is shared with a client only when you deliberately share that one — never by default, never in bulk. When they open it, that is recorded, so you know whether the thing you wanted them to have has actually reached them.

What they can ask for themselves

A copy of their record, the register of who it has been disclosed to, a correction, a restriction on a disclosure — each from a button in their own account rather than a phone call they have to work up to. Each one arrives to you as a dated obligation with the legal deadline attached, which is what it is.

Their money, in the same place

Invoices, receipts, what is outstanding, a payment plan's schedule, and the good faith estimate they were given, kept exactly as they received it.

When a client moves on

The client decides what travels. Not you, and not us.

A client inside a clinic moves from one clinician in it to another — they outgrow the work, or need somebody who does a different kind of it. The care moves. What the next clinician gets to read is a separate question, and it is answered in exactly one place: by the client.

You offer; they answer; both have to say yes. The route that writes their answer hangs off their own account and exists nowhere else — there is no version of it scoped to a therapist, a clinic or an administrator, and the database refuses a row whose decider is not the client it is about. (Leaving the practice altogether is a different thing: that is a record request or an export, further up this page.)

The letter is required, and they cannot stop it

A letter goes to the receiving clinician whatever else the client decides — because handing somebody on with nothing at all makes that person re-tell everything, including the hardest parts, to a stranger. It is your own professional communication, so they cannot stop it; they do read it in full, and they may ask you to correct it or add their own words to it.

And they are told at the moment the move happens, rather than left to notice. A record changing hands without the person knowing is the thing this whole step exists to prevent.

The record itself is theirs to release, by category

Five categories, chosen one at a time rather than all or nothing: the session notes, the diagnoses, the history, the medications, and the recordings with what the assistant heard in them. Somebody can release the diagnoses and withhold the notes, and that is a legitimate answer rather than an obstruction. Choosing none of them is also an answer, and it is recorded as one — which is why no answer yet and an answer of nothing are two different states here.

Until they answer, the letter is all there is

No default of "everything unless they object", and no waiting period that quietly becomes consent. The receiving clinician has the letter and knows that is what they have.

The gap is declared, never itemised

The receiving clinician is told plainly that the client chose not to release part of the record. They are not told which part, or how much — a list of withheld categories is a description of the withheld material, and the client did not consent to that either.

Audio and transcripts need a separate yes

A kept recording of a session and the text of what was said do not travel with the notes. They move only on their own explicit permission, because they contain the client's own voice and yours.

Booked sessions do not move, and every read is marked

A client who booked with you must not arrive and find somebody else, so their existing appointments stay where they are and the count comes back — for a person to rebook or cancel, out loud. And when the new clinician reads what came before, the access log records it as a read under a handover rather than as a therapist looking at their own client, because those are not the same event and the second one hides the first.

How long things are kept

Eight kinds of record, each with a period and the reason inside it.

"We keep data as long as necessary" is the sentence every privacy policy uses and nobody can act on. Pexido's retention is a schedule: eight record types, an explicit period for each, and the reason written into the row itself rather than inferred later by whoever is asked.

The clinical record: seven years from the last session

And for somebody treated as a minor, seven years past legal majority — whichever of the two falls later, which is the clause most schedules leave out and the one that actually governs a paediatric caseload. Your private psychotherapy notes are their own category and keep the same two periods, separately, because they are a separate record.

Six years for consents, disclosures, requests and incidents

The record of what somebody agreed to, who their information went to, what they asked for and what went wrong — kept as long as the obligation to account for it lasts.

Seven years for financial records, six for access logs

Money because of the tax and dispute window. Access logs because the question "who read this chart, and when" has to be answerable for as long as somebody might ask it.

Where the number comes from a law, the law is named

And where it is Pexido's own judgement, the row says that instead of implying an authority nobody gave us. A retention period presented as a legal requirement when it is really a product decision is a small lie with a long life.

Nothing goes on a timer

Reaching the end of a period makes a record eligible for disposal; it does not delete it. Disposal is off by default, every clinical table refuses deletion outright, and no clinical record has ever been removed by the passage of time on this platform.

One of these is still open

How long a kept session recording and its transcript should live is not settled. The working answer is seven years, but whether that is a floor or a ceiling, and from which date it runs, is with counsel along with the rest of the schedule. Until it is decided, nothing deletes them — and we would rather tell you the question is open than publish a number we are going to change.

If you prescribe

Built knowing that not every clinician does talk therapy.

Psychiatrists and psychiatric nurse practitioners get told to use software designed for somebody else's visit. The parts of Pexido that would get a medication visit wrong were changed rather than left for you to work around.

Pexido does not prescribe, and will not say otherwise

Prescriptions are written, signed and routed by a certified e-prescribing system — Surescripts-connected and EPCS-certified — in its own interface, under your practice's agreement with that vendor. Pexido's side is enrolment, the way into that interface, and the medication record that comes back. The two-step verification EPCS requires belongs to you at the moment of signing, inside their flow, not to your Pexido login.

A medication list that admits when it is old

The prescription is written in your e-prescribing system; this is the record of it. Two lists kept by hand drift — a dose changes there, nobody changes it here, and months later another clinician or an emergency department reads the old one. A medication list is the one place in a chart where being out of date can hurt somebody, and a stale list looks exactly like a current one. Pexido cannot stop the drift. It stops the list looking confident about it, and says how long it has gone unreviewed.

Coding that knows who held the visit

A twenty-two minute medication visit is not a psychotherapy hour, and the code it supports depends on the clinician, not only on the clock. The billing check reads your profession and role rather than assuming every appointment on the platform was therapy — which is what it assumed while every clinician here was a therapist.

The rest of the record is the same record

Diagnoses, treatment plans, assessments, the timeline, documentation help and export all behave the same for you as for anyone else. Prescribing is a capability on your account, not a separate product with its own subscription.

Where this stands: the medication record and the prescriber-aware coding are built. The connection to a certified e-prescribing vendor is built up to the seam, and no vendor is contracted yet — so treat prescribing itself as coming, not as something you can do here today. We would rather tell you that now than have you find out after you moved your practice.

Keep reading

The rest of the therapist side.

Next Insurance Coverage before the session, a claim that is checked before it leaves, and the answer read back. Next Clinics Several clinicians, three money models, and a wall between them the software keeps. Next Pricing What the base carries, what is metered, and the five commitments accepted on their own.

A first group of therapists is being invited now.

Early profiles are free, and the people in that first group help shape what gets built next. Send your name, your state and your specialty — or just ask to be told when it opens, and we will leave it there.

Create your profile

The chart, beside the calendar that filled it.