A note is written against a template, saved as a draft while the visit is fresh, and completed when it's done. Completed notes lock, which is what makes them worth something later.

Start the note

1

Open the patient's record and their Notes section

From the appointment on the calendar, the note is linked to that visit automatically: No note for this appointment yet. This note will be linked to it automatically.

2

Choose a template

New note — choose a template lists the clinic's templates. Pick one and the fields appear.

3

Fill it in

Note title is optional and defaults to the template name. Required fields are marked. A Body chart field opens the chart to draw on; a File attachment field takes photos or documents; a Signature field accepts a drawn signature or a typed full name.

4

Save as a draft, or Complete

Draft saved keeps it editable. Complete checks the required fields first: Please fill in all required fields before completing. Moving to another note or New note with unsaved changes asks Your changes to this note aren't saved. Leave it without saving?; if a save fails, Couldn't save the note just now. Your text is still here: try again., and Cancel puts the note back as it was last saved. If a colleague saved the same note while you had it open: Someone else changed this note since you opened it. Copy anything you need, then reopen the note to see their changes.

The Notes section of a patient record with a draft note open, showing the template fields, a body chart with marks, and the Complete and Draft buttons.
A follow-up note in progress on Amira Haddad's record, linked to today's Physio appointment, with a body chart field marked up.

Draft, Completed and Locked

A draft can be edited and archived by anyone with the clinical permission. Once completed, the note shows Locked: Completed notes can't be changed. Add a new note for any correction. This is deliberate, because a clinical record that can be rewritten after the fact is hard to defend. Write the correction as a new note that refers to the old one. Notes are never deleted; archiving a draft hides it under Show archived, where it can be restored.

Completed notes are locked. A correction is a new note that refers to the old one. This is what makes the record defensible, so complete a note only when it's finished.

Share or print

  • Send by email attaches the note as a PDF to an email to the patient or another address, with a short message. The print settings on the template decide the heading and patient details.
  • Export PDF downloads the same document.
  • The note is also part of the patient's data export and of a record share.

Who can read and write notes is controlled by the clinical permission and by Patient Privacy, which can restrict notes to the treating practitioner.