Clinical Notes
ConceptOverview
A Clinical Note records clinical information for an encounter. Notes help the care team understand what occurred during the visit and support continuity of care.
When is it used?
Create or update a clinical note when documenting a visit. Your clinic may require specific templates or sections.
How to create a clinical note
ProcedureBefore you start
- The client and encounter are available
- You have permission to create clinical notes
- You know which note template your clinic expects
Steps
- Open the client or appointment context.
- Open the related Encounter.
- Select New Clinical Note (or Add Note).
- Complete required sections.
- Save as draft if you are not ready to sign.
Screenshot placeholderClinical note editor with template sectionsAdd image under docs/public/images/
TIP
Save drafts frequently. Sign only when the note is complete and accurate.
Related concepts
- Encounter
- Signature
- Addendum
- Appointment