Clinical charting, SOAP notes, codes and templates

Clinical charting is part of the Professional plan and up, and it is built around one rule, a saved note is never silently changed. This guide walks through what the chart holds and how each piece fits together.

SOAP notes and billing codes

Each visit note follows the familiar SOAP structure, and you attach a CPT code and one or more ICD-10 diagnosis codes to the visit as you write it. Those codes are what later fill in a superbill without you retyping anything, and a single visit can carry more than one billable procedure when the session covered more than one service.

Clinical facts and care plans

Allergies, medications, vitals and BMI live as structured clinical facts on the patient record, separate from the narrative notes, so they are easy to scan at a glance. A care plan sits alongside the notes and can be shared with the patient in their portal if you choose to.

Templates for the notes you write often

Note templates under Templates give you a starting structure for the visit types you repeat most, so you are editing rather than starting from a blank page each time.

Earlier visits, right where you need them

Previous visits for the same patient are shown alongside the one you are writing, so you do not have to leave the note to check what happened last time.

Append-only, with amendments instead of edits

A saved note cannot be edited or deleted. Correcting one means saving a new version that points back to the note it replaces, and the earlier version stays on record. Patients can ask for a correction too, through an amendment request they submit from their portal, which you accept or decline from your own queue.

A copy for the patient

Patients have a right to a copy of their record, and RafaNest supports giving them one. See what patients see in their RafaNest portal for what they can view and request on their own.

If visits are recorded, the AI scribe drafts the note for you and lands it in the same append-only chart described here.