At Rula, we know documentation is a vital part of your clinical work- and we also know it can be one of the most time-consuming and draining parts of your day. That’s why we’re excited to offer Recap, a note-taking tool designed to support you.
What Is Rula’s Recap?
Think of it as your documentation co-pilot: with your patient’s informed consent, the tool captures your session content and generates a draft note aligned using your clinical expertise and evidence-based practices as it relates to documentation. You review and revise the draft before finalizing, maintaining full clinical and ethical ownership of your documentation.
Why Providers Love It: The Benefits
More Time, Less Burnout
Providers often spend 10-15 minutes per note (O’Neill et al., 2021), adding up to many hours spent outside of sessions each week. This tool helps reduce that burden, giving you time back for rest, fun, learning, or growing your practice- the choice is yours!
Be More Present
Knowing your tool is capturing session content can free you to stay attuned to patients, particularly in high-emotion, trauma-focused, or otherwise complex sessions where split attention is costly to the therapeutic alliance (Norcross & Lambert, 2019).
Keep Your Clinical Voice
The tool’s drafts are a starting point- not a finished product. You remain the clinical author, shaping notes with your voice, judgment, and professional standards.
Promote Consistency and Quality
These generated notes utilize Rula’s existing intake and progress note formats. This tool generates notes that are aligned with Rula’s Network Quality Standards and documentation expectations. These templates are designed to capture information and document it in a way that supports continuity of care, meet payor requirements, and facilitates clearer communication in multidisciplinary settings (Wright et al., 2022).
Best Clinical Practices for Using Recap
Using Recap can strengthen clinical care when paired with thoughtful documentation. We highly recommend reading this article about how to talk to patients about this tool:
Before the Session
- Obtain and document informed consent from the patient before enabling the Recap feature. Be sure to engage your patient in an informed consent conversation related to the tool. Revisit the conversation as needed.
- Discuss the risks and benefits of using this tool and how to opt out
- Let them know that Recap supports your workflow, but you are still the sole author and responsible party.
- Review technical readiness: Ensure your microphone is working, your space is private, and no background noise or disruptions will compromise quality. It can be disappointing to realize that the entire session occurred and the notetaking tool didn’t capture any of it!
During the Session
- Monitor for patient response: If a patient seems uneasy about the tool capturing sensitive discussions, consider pausing or revisiting informed consent.
After the Session
- Read every draft thoroughly: Never accept a draft as-is. Look for errors, tone mismatches, or missing clinical nuance. Review the note to ensure that all relevant clinical and diagnostic data is accurately captured in your note. This includes making sure DSM-5 diagnostic criteria has been met, accurate medication dosing and frequency and documentation of relevant safety information.
- Personalize the language to reflect your style and the patient’s story. Make it warm, specific, and patient-centered, and revise to ensure that it protects the patient’s confidentiality.
- Include cultural, contextual, and identity-relevant factors- this is an ongoing opportunity for growth for all note taking tools.
- Ensure that diagnoses and risk assessments reflect your clinical judgment. Given the importance of effective documentation to reduce liability risk for the provider, it is absolutely critical that these critical components are appropriately documented.
- Double-check sensitive or legally relevant content (e.g., suicidality, clinical risk, child abuse reports, court-related content) for accuracy and clarity.
- Use the draft as a reflection tool- not just a record. Review what stood out in the session and what it means for your treatment plan.
Ethical Considerations
AI-driven tools are becoming more common in healthcare, and mental health is no exception. But unlike EHRs or HIPAA, which have decades of guidance, there’s not yet a consistent ethical standard for how providers should use AI tools such as note taking assistants in treatment. While we know several professional boards are currently in the process of defining their position related to AI, this is still a new frontier, which can generate feelings of both excitement and uncertainty.
So, where do we turn?
We look to our ethical foundations that protect our patients: transparency, informed consent, cultural humility, and sound clinical judgment. These principles guide how we use any new tool- especially one that touches something as sensitive as psychiatry and important as mental health.
A Quick Look at AI’s Role in Care
- In the 1950s–90s, early AI systems focused on diagnostics and structured decision-making in the provision of medical care. These tools were not yet being used in the mental healthcare space.
- By the 2010s, mental health researchers began using AI for transcription, symptom analysis, and self-guided support (e.g., chatbots).
- Today, AI is entering the mental health space primarily through supportive tools, like note taking assistance, chart reviews, risk flagging, and engagement tracking.
These tools are designed to assist and support providers, not to replace them. While many are built with privacy and safety in mind, their ethical use depends on the human behind the tool: you.
Ethical Values at Play
Using AI in psychiatry calls for careful alignment with license-specific Code of Ethics, HIPAA, and best practices in digital mental health, even as formal AI-specific guidelines are still emerging.
1. Informed Consent and Transparency
Patients must consent explicitly to using the tool. You’re responsible for explaining:
- What the tool does
- What it captures (and doesn’t)
- That you review and revise everything
Informed consent isn’t just paperwork- it’s a series of conversations rooted in trust.
2. Privacy, Security, and HIPAA Compliance
While Rula Recap is HIPAA compliant and encrypts all data, you should only use the tool in secure settings and remain alert to the security of your own device.
3. Bias and Equity
AI systems can unintentionally reproduce language biases. As the clinician, it’s your role to ensure that documentation reflects culturally sensitive and equitable care.
Example: An AI might mislabel emotionally expressive behavior as “dysregulation” unless you contextualize it with clinical and cultural awareness.
4. Clinical Judgment Is Foundational
No AI tool can replace a human provider's ability to detect subtle changes in your patient's responses and mannerisms, manage safety risks or interpret meaning. Recap is there here to assist you but you are the ultimate clinical decision maker and note author.
Support Balance in Everyday Practice
You decide how this tool fits into your workflow. Use it when it saves you time, skip it when it doesn’t, and shape each note your way. Your feedback helps us keep improving it to better support both you and your patients.
This tool exists to lighten your load and make documentation more manageable. It reflects Rula’s commitment to your balance, well-being, and professional growth. When providers have space to breathe, patients receive their best care.
Still Have Questions?
Check out our Rula Recap FAQ, or reach out to Rula’s Clinical Quality team. We’re here to support you every step of the way.
References
- American Psychological Association. (2017). Ethical Principles of Psychologists and Code of Conduct.
- Luxton, D. D. (2021). Artificial Intelligence in Behavioral and Mental Health Care. Academic Press.
- Norcross, J. C., & Lambert, M. J. (2019). Psychotherapy Relationships That Work. Oxford University Press.
- O’Neill, K. E., et al. (2021). “Therapist Burnout and Documentation Burden: A Call for Systemic Change.” Journal of Behavioral Health Services & Research.
- Wright, J. H., et al. (2022). “Best Practices in Electronic Health Record Documentation for Mental Health Providers.” Psychiatric Clinics of North America.
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