How to Sign a Clinical Note
ProcedureOverview
Signing a clinical note confirms that the documentation is complete for the author’s responsibility level. After signing, changes are typically restricted and may require an addendum.
Before you start
- The clinical note is complete and reviewed
- You are the authorized signer (or co-signer, if applicable)
- Required fields and attestations are filled in
Steps
1. Open the clinical note
Locate the draft note from the encounter or documentation list.
Screenshot placeholderList of draft clinical notes awaiting signatureAdd image under docs/public/images/
2. Review the note content
Check client identity, date of service, and clinical content for accuracy.
3. Select Sign
Select Sign (wording may be Sign Note or Finalize depending on configuration).
Screenshot placeholderSign clinical note confirmation dialogAdd image under docs/public/images/
4. Confirm signature
Complete any confirmation prompt. Verify the note status changes to Signed.
::: important Do not sign a note for another person. Co-signature workflows, if enabled, are role-specific. :::
5. If a correction is needed later
Use an Addendum rather than editing signed content when your clinic policy requires it.