> ## Documentation Index
> Fetch the complete documentation index at: https://help.clinikehr.com/llms.txt
> Use this file to discover all available pages before exploring further.

# Write a clinical note

> Create a progress note from a template, a blank page or a recording, then sign and lock it — and countersign a colleague's.

export const AuditNote = ({action = 'This action'}) => <div className="ck-callout ck-callout--info" role="note">
    <p className="ck-callout__body">
      {action} is written to your workspace's audit log with your name, the
      record touched and the time — a HIPAA requirement, and one you can review
      yourself under <strong>Audit Log</strong>. See{' '}
      <a href="/platform/security/audit-log">Audit log</a>.
    </p>
  </div>;

export const StillStuck = ({topic}) => <div className="ck-callout ck-callout--note" role="note">
    <p className="ck-callout__body">
      <strong>Still stuck{topic ? ` with ${topic}` : ''}?</strong>{' '}
      Check <a href="/platform/help/troubleshooting">Troubleshooting</a> first —
      it covers the failures we see most often. If that does not resolve it,{' '}
      <a href="/platform/help/contact-support">contact support</a> and include
      your workspace name and the time the problem happened, so we can find the
      matching entry in your audit log.
    </p>
  </div>;

export const TaskHeader = ({before, time, after}) => <div className="ck-task">
    {before ? <div className="ck-task__cell">
        <div className="ck-task__title">Before you start</div>
        <p className="ck-task__body">{before}</p>
      </div> : null}

    {time ? <div className="ck-task__cell">
        <div className="ck-task__title">Takes about</div>
        <p className="ck-task__body">{time}</p>
      </div> : null}

    {after ? <div className="ck-task__cell">
        <div className="ck-task__title">When you're done</div>
        <p className="ck-task__body">{after}</p>
      </div> : null}
  </div>;

export const Path = ({steps = []}) => <span className="ck-path">
    {steps.map((s, i) => <span key={i} className="ck-path__step">
        {i > 0 ? <span className="ck-path__sep" aria-hidden="true">
            ›
          </span> : null}
        {s}
      </span>)}
  </span>;

export const Availability = ({editions = ['all'], plans, roles, note}) => {
  const list = editions.includes('all') ? ['clinic', 'pharmacy', 'lims'] : editions;
  return <div className="ck-avail" role="note" aria-label="Feature availability">
      <span className="ck-avail__label">Available in</span>

      {list.map(e => <span key={e} className={`ck-pill ck-pill--${e}`}>
          {EDITION_LABELS[e] || e}
        </span>)}

      {plans ? <span className="ck-avail__label">Plan</span> : null}
      {plans ? <span className="ck-pill ck-pill--plan">{plans}</span> : null}

      {roles ? <span className="ck-avail__label">Who</span> : null}
      {roles ? <span className="ck-pill ck-pill--role">{roles}</span> : null}

      {note ? <span className="ck-avail__note">{note}</span> : null}
    </div>;
};

<Availability editions={['clinic']} plans="All plans — signing, locking and the AI writing tools need a paid plan" roles="Any clinical staff member" note="This screen is the same on every plan. Your workspace calls the people it serves clients (Solo & Team) or patients (Enterprise) — the guide uses both." />

Notes are the standalone documentation surface: a note you write about a person without going through a department queue. Solo and team plans do all their clinical documentation here.

<Tabs>
  <Tab title="Solo and team">
    <Path steps={['Sidebar', 'Notes', 'New Note']} />
  </Tab>

  <Tab title="Enterprise">
    <Path steps={['Sidebar', 'Outpatient', 'Clinic Notes', 'New Note']} />
  </Tab>
</Tabs>

<TaskHeader before="The person you are documenting must already exist as a client or patient" time="5 minutes" after="A note saved as a draft, or signed and locked against the person's chart" />

## Where everything is

The left rail is headed **Clinical Notes** and holds **New Note**, **Templates**, **Custom Templates** and **Snippets**, then an **AI** section with **AI Notes**. **AI Notes** opens a sheet over the page rather than taking you somewhere else.

**New Note** opens the **New Progress Note** dashboard, which offers three ways in:

| Card              | Use it when                                                   |
| ----------------- | ------------------------------------------------------------- |
| **Use Template**  | "Start from a template" — the structure is already decided    |
| **Blank Note**    | "Start from scratch"                                          |
| **AI Note Taker** | "AI-powered note generation" — from a recording or a document |

Below those sit **Waiting on you (n)** — notes needing your countersignature — a **Quick Note** card, and **Recent Notes**.

## Write a quick note

<Steps>
  <Step title="Fill in the Quick Note card">
    Enter a **Note Title**, then choose a **Template Type**: SOAP Note, Progress Note, Initial Assessment, Therapy Session, Discharge Summary, Treatment Plan or General Note.
  </Step>

  <Step title="Attach it to a person">
    Use the **Client** picker — "Search clients..." — to choose who the note is about.

    A draft saves without one. A final note does not: you will be told "Please select a client before saving the final note".
  </Step>

  <Step title="Add tags and write">
    **Tags** ("Add a tag...") make the note findable later. Write the body in **Note Content**.
  </Step>

  <Step title="Save, or sign and lock">
    Save keeps it as a draft you can come back to. **Sign & Lock** finishes it — see below.
  </Step>
</Steps>

## Sign and lock

Select **Sign & Lock** to open the **Sign & Lock Note** sheet. Choose the **Signing Provider**, then add the **Provider Signature** — type it or draw it, under the heading **Electronic Signature** — and confirm.

A locked note tells anyone who opens it "This note is locked and cannot be edited". If you need to change it, select **Unlock Note**.

## Countersign a colleague's note

The **Waiting on you (n)** card collects notes signed by someone you supervise: "Notes signed by a colleague you supervise. They are not final until you countersign."

Select **Read the note**, read it properly, then countersign. Until you do, the note is not final. Countersigning can be granted to specific people — see [Permissions](/platform/team/permissions).

## The AI writing tools

Two tools sit in the editor toolbar, both on the text you have already written:

* **AI Rewrite** — rewrites a passage you select.
* **AI Autocomplete** — suggests the next few words as you type. Press Tab to accept the suggestion, or keep typing to ignore it.

Both need the Essential plan or above. To generate a whole note from a recording or an uploaded document instead, use [the AI Note Taker](/clinic/clinical/ai-notes).

<Note>
  AI text is a first draft, never a record. Read every sentence before you sign — your signature makes it yours.
</Note>

## Check it worked

The note appears under **Recent Notes** with the right person's name against it, and on that person's chart. A signed note shows the signing provider and cannot be edited until it is unlocked. If you sent it for countersignature, it stays in your supervisor's **Waiting on you (n)** list until they act.

<AuditNote action="Opening a clinical note" />

## If something goes wrong

<AccordionGroup>
  <Accordion title="Sign & Lock is locked behind an upgrade">
    **eSignatures & Locking** needs the Starter plan or above. On the Free plan you can write and save drafts but not sign them. See [Change your plan](/platform/plans/change-plan).
  </Accordion>

  <Accordion title="I have hit a limit on new notes">
    The Free plan caps how many clinical notes you can write each month. The count resets at the start of the next month; the Starter plan and above remove the cap.
  </Accordion>

  <Accordion title="AI Rewrite or AI Autocomplete is not there">
    Both need the Essential plan or above. They are separate from the AI Note Taker, which is an add-on rather than a plan feature.
  </Accordion>

  <Accordion title="It will not save as final">
    A final note needs a client or patient selected. Choose one in the **Client** picker and save again — and if the person does not exist yet, add them first in [Register patients](/practice/daily/clients).
  </Accordion>

  <Accordion title="A locked note needs correcting">
    Select **Unlock Note**, make the correction and sign it again. Both the lock and the unlock are recorded in your [audit log](/platform/security/audit-log), so amend rather than working around it.
  </Accordion>
</AccordionGroup>

<StillStuck />