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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.

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Before you start

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

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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.

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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.

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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.

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Only the author changes a note

A note belongs to the person who wrote it. Only that person can change what it says — the editor and autosave are switched off for everyone else, owners and managers included. A colleague’s note opens read-only under a banner that says Written by their name and the date, with the line “You can read this note and add a follow-up note. Only its author can change what it says.” Owners and managers can still read the note, unlock it and countersign it. What they cannot do is rewrite someone else’s words. If you are shown “This note was written by …” when you try to save, someone else wrote it. Nothing you typed is lost to their note; add your own follow-up note instead.

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Add a follow-up note

Use Add follow-up note when you need to add to a note you did not write — or to a note that is already signed. It opens a sheet where you write your entry, sign it (typed or drawn) and confirm. Select Sign and add. Your follow-up note appears under the original, with your name, your role and the time you signed it. The original is never edited. Follow-up notes show in the note itself, in the client’s chart and in the PDF you export. A doctor who sees a patient return the same day uses a follow-up note rather than reopening the earlier visit. A follow-up note is part of the record: it cannot be edited or removed afterwards. If you made a mistake in one, add another. Adding and signing a follow-up note is included on every plan, the Free plan too.

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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.

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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.
  • Draft with…, inside the note editor, drafts from text you already have — dictation, a transcript, or your own rough notes.
Both the Draft with… button and the AI Note Taker use whichever assistant your hospital has chosen — ClinikEHR’s own, or an outside one your hospital connects with its own account. See Choose a note assistant.
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.

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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.

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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.

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Common issues

You opened a note written on a note form from somewhere other than the client’s record — for example View under Recent Notes. Nothing has been lost: every answer is still on the note. Open the client, go to Notes, and select the note there to read or continue it. See Open a note written on a note form.
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 is read-only because you did not write it. The banner at the top says who did. Select Add follow-up note to add your own signed entry under theirs. An owner or manager can read, unlock and countersign it, but cannot rewrite it either.
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.

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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 wrote before note forms: they still appear in the picker when you start a note, but they are read-only. A department that wants to standardise its own documentation now builds a note form — select Create a note form on either page. See Note templates.
No. One person writes and signs; a supervisor countersigns. A second clinician who has something to add writes their own follow-up note, which sits under the original with their name on it. There is no simultaneous editing, which is deliberate — a clinical note has an author, and the signature says who it is.
No. A manager can read it, unlock it so its author can correct it, and countersign it. They can add a follow-up note of their own, but the original wording stays the author’s.
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. Only the Free plan withholds them.