Sessions & charting

Starting a session

Every session is tied to a real appointment — this keeps a visit's date, time, service, and provider in exactly one place instead of two records that could disagree. There are two ways to start one:

• From an already-booked appointment — use the Start session link on the Calendar. The appointment's service, provider, location, and time carry straight into the chart, read-only.
• Walk-in or retroactive charting — choose New session from a patient's page. Pick the service, provider, location, and date/time (defaulting to now), and a matching appointment is booked for you automatically as part of saving the session — no separate booking step.

Either way, the form itself is laid out as four tabs, with a summary panel alongside it that stays visible as you move between them — clicking a summary section jumps you straight to the tab that edits it:

• Notes — any org-defined custom session fields plus a freeform note for the visit, written with a formatting toolbar rather than a plain text box — bold/italic, links, lists, checklists and headings
• Pulse & Tongue — pulse position and quality, tongue observations
• Pattern & Technique — the TCM pattern identified and the technique applied
• Points — the acupuncture points used, with laterality (left / right / bilateral)

The point picker filters a large point list by name so you don't have to scroll a long checklist — a meridian expands automatically once it has a selection or a matching filter.

There's no built-in pain/symptom score — practitioners track outcomes differently enough (0–10? a named scale? per-complaint?) that it's a fit for custom session fields instead of a one-size-fits-all built-in. Any custom fields your organization has defined (in Settings) show up at the top of the Notes tab.

Starting from a protocol or a past session

A protocols strip on the session form lets you apply a saved protocol with one click, pre-filling points, pulse/tongue, and pattern/technique so you're editing instead of starting from a blank chart. See Protocols.

When the patient has an earlier session, a Copy from last session button does the same thing from their own history instead of a saved protocol — it carries points, pulse/tongue, pattern/technique, and any diagnosis codes forward (not the note or custom fields, which describe that visit, not this one). Next to it, Clear session resets every field back to a blank draft in one click. Both are safe to click even after other charting — nothing is lost, since History and Undo can always bring back what was there before.

Editing and deleting a session

Open any past session from the patient's session list to edit it in the same tabbed form. Deleting a session sends it to the trash rather than removing it permanently — see Trash & recovery.

History and undo

Every save is kept, not just the latest one. Click History in the editor to open a right-hand drawer listing every save, status change, restore, and sign/unsign event for the session, newest first, with who made each change and — where there's something to compare against — a quick summary of what changed (points added/removed, pattern changed, notes changed, and so on). A changed note or other long field is click-to-expand, revealing the actual before/after wording rather than just "changed." A run of consecutive plain saves collapses into one expandable group so a long editing session doesn't turn into a wall of near-identical rows.

Any past version can be brought back with Restore this version. Restoring never rewrites history — it loads that old snapshot and writes it forward as a brand-new entry at the top of the list, so the log itself is proof nothing was silently erased.

The Undo button next to History is a separate, narrower shortcut: it cancels the note field's pending autosave (notes save on a short debounce, so there's a brief window where a keystroke hasn't been persisted yet) rather than reverting something already saved. Once that window has passed, clicking Undo again steps back through your own most recent saves one at a time, the same as clicking Restore in the History drawer — it's only ever offered for saves you're still actively walking back from, not as a general-purpose replacement for the drawer.

Signing and locking

Toggling a session to Sign session locks it against ordinary status changes and marks it as the attested record of the visit. A signed session can still be edited — those edits are saved and logged in the History drawer as Amended after signing rather than a plain save, so it's always clear from the log which changes happened before versus after signing. Unsigning (Unsign) reopens the session for normal status changes again.

Signing also prunes the fine-grained pre-signature save history down to a single snapshot as of the signature — the detailed autosave-by-autosave trail is only useful while a note is still being drafted; what matters afterward is the signed version and any amendments made after it.

Draft and complete

Every session starts as a Draft — including one you fill out in a single sitting — until you flip the toggle at the top of the editor to Complete. A patient's session list and the Calendar both show a draft badge, so an unfinished note never quietly looks the same as a finished one.

Once a session exists for an appointment, the same Calendar row shows Draft note or Charted instead of Start session — click it to jump straight back into that session.

Superbill export

Wherever a session exists on an appointment row, a small receipt icon opens a page to generate a patient-facing superbill — a document a patient can submit to their own insurer for out-of-network reimbursement. It suggests CPT codes and units from the visit's treatment minutes and technique, and lets you pick the diagnosis code(s) that apply before generating a PDF.

Treatment minutes default to the appointment's scheduled length, or to the service's own treatment-time default if one is set (Settings > Scheduling, on the service) — useful when a slot routinely includes intake or rest time that isn't hands-on contact. Either way you can edit the number for a single visit, and the suggested units update as you type. What you leave there is saved with the visit, so regenerating the same superbill later gives the same result.

The diagnosis list is filterable, and the codes you pick are remembered two ways: Copy from last session carries them onto a new chart, and Save as this patient's default makes them the suggestion on every future visit for that patient. A visit that reaches the superbill page with no diagnosis yet offers those saved defaults — or, failing that, whatever was used at the patient's last coded visit — as a one-click suggestion rather than filling them in silently.

The PDF separates who is being billed under — your practice name, address, phone and Tax ID — from the place of service, meaning the location the visit actually happened at and its CMS place-of-service code. With one location those are the same thing and the address isn't repeated. A practice with a second location can give it its own billing details under Settings > Scheduling, and superbills for visits there use them automatically.