Skip to main content
Clinic Notes is the hospital’s standalone documentation surface: a note about a patient written without going through a department queue. Use it for a ward review, a handover, a discharge summary or anything else that is clinical writing rather than an outpatient encounter. Documentation that belongs to an outpatient visit goes on the consultation chart instead.

​
Before you start

Clinic Notes has no care-area switch — it is always in the sidebar on Enterprise, and every feature on this page is included in the plan. The patient must exist first; register them in Patients.

​
What you’re looking at

The module has its own left rail headed Clinical Notes, holding New Note, Templates, Custom Templates and Snippets, then an AI section with AI Notes. AI Notes opens a sheet over the page rather than navigating away. New Note opens the New Progress Note dashboard, which offers three ways in: Below those sit three things. Waiting on you {n} collects notes needing your countersignature — “Notes signed by a colleague you supervise. They are not final until you countersign.” A Quick Note card lets you write without opening a full editor. And Recent Notes lists what the hospital has written lately, with Search notes…, a Filter by type control (All Types by default) and columns for Status — Draft or Final — plus Date, Created By and Patient. A brand-new hospital sees the three entry cards and an empty Recent Notes list. Nothing is wrong; nobody has written anything yet.

​
Write a quick note

1

Fill in the Quick Note card

Enter a Note Title — “Enter note title…” — then choose a Template Type: SOAP Note, Progress Note, Initial Assessment, Therapy Session, Discharge Summary, Treatment Plan or General Note.
2

Attach it to a patient

Use the picker, which is labelled Client and searches with “Search clients…” wherever you are on the platform. 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”.
3

Add tags and write

Tags (“Add a tag…”) make the note findable later. Write the body in Note Content — “Start typing your note content… Type / for snippets”, which is how you pull in a saved snippet mid-sentence.
4

Save, or sign and lock

Saving keeps it as a draft you can come back to — “Draft saved successfully”. Sign & Lock finishes it.

​
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 modified” and carries a Locked badge. To correct it, select Unlock Note, amend, and sign again. Both the lock and the unlock are recorded.

​
Countersign a colleague’s note

Notes signed by someone you supervise appear under Waiting on you {n}. Select Read the note, read it properly, then countersign. Until you do, the note is not final — the supervising signature is what makes it one.

​
Use AI, carefully

Three tools, and they are different things:
  • AI Rewrite rewrites a passage you have selected.
  • AI Autocomplete suggests the next few words as you type. Press Tab to accept, or keep typing to ignore it.
  • AI Note Taker generates a whole note from a recording or an uploaded document, and its sessions are managed from AI Notes.
AI text is a first draft, never a record. Read every sentence before you sign — your signature is what makes the words yours, and a signed note is a legal document about a real patient. Never sign AI output you have not checked against what actually happened.

​
Who can do this

Two behaviours worth knowing. Permission enforcement is opt-in per person: someone never saved in the permissions sheet is unrestricted, and the sheet warns “Saving starts enforcing” — so nothing changes for existing staff until they are saved once. And a denied action is recorded in the audit log while an allowed one is not, so hiding Clinic Notes in Role Navigation is a convenience, not a security boundary. See Permissions.

​
Check it worked

  • The note appears under Recent Notes with the right patient against it, and on that patient’s chart.
  • Its Status reads Final rather than Draft.
  • A signed note shows the signing provider and refuses edits until unlocked.
  • A note you sent for countersignature stays in your supervisor’s Waiting on you {n} list until they act.

​
Common issues

A final note needs a patient selected. Choose one in the picker and save again. If the patient does not exist yet, register them first in Patients.
It has been signed. Select Unlock Note, make the correction and sign it again — amending a signed note is expected, working around it is not.
Countersignature only reaches the supervisor the note was signed to. Check with the author which provider they picked as the Signing Provider, and check your own role can countersign.
That shortcut works inside Note Content only, and needs at least one saved snippet. Create some under Snippets in the left rail.
The picker keeps that label across every plan. It searches your patient list; the word on the button is the only difference.
Use Search notes… and clear Filter by type, which persists between visits. Recent Notes shows the newest first, so an older note may simply be further down.

​
FAQ

A consultation documents an outpatient encounter that came through triage and a department queue, and can carry orders. A clinic note is free-standing documentation about a patient — a ward review, a handover, a discharge summary — with no queue behind it.
Templates are the ones supplied with the product. Custom Templates are the ones your hospital writes, so a department can standardise its own documentation. Both appear in the same picker when you start a note.
One person writes and signs; a supervisor countersigns. There is no simultaneous editing, which is deliberate — a clinical note has an author, and the signature says who it is.
Yes, as soon as it is attached to a patient. A draft appears as a draft; the chart shows the current state rather than waiting for a signature.
Yes. Every note feature — signing, locking, countersignature, templates, snippets and the AI writing tools — is included on Enterprise.