📋Clinical Documentation & Charting

All patient interactions must be thoroughly documented. For video sessions, the AI Charting Assistant simplifies documentation and charting by auto-generating a SOAP note for you to review and submit. For phone or in-person sessions, manual documentation is required and should adhere to professional standards of practice.

Each note should accurately reflect the session content, time spent, and relevant care decisions. Session statuses must be updated correctly— no-shows, reschedules, and late cancellations must not be deleted, but appropriately labeled. Deleting appointments causes back end system issues, so please do not delete appointments.

Berry Street can help support in-person sessions for Provider Sourced patients. To enable this, email [email protected]. Our team will update your account and send instructions. Note: assisted charting is unavailable for in-person sessions—you must manually document clinical notes, time in/out, and appointment status (see manual documentation video and guide).

👉 Clinical Documentation & Charting section covers:

• Billing Integrity and Documentation Standards for Berry Street Providers

• Clinical Note Templates

• Medical Necessity & Documentation

• Preventative & Medical Coverage

• Documentation Standards for MNT Billing

• Clinical Documentation Review Criteria

• Manual Note-Talking & Documentation Guidance

• In-Person Sessions