> ## 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 clinic note

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

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="Enterprise — every note feature is included" roles="Any clinical staff member" note="No care area needed — Clinic Notes is always in the Enterprise sidebar" />

**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](/hospital/outpatient/consultation) chart instead.

<Path steps={['Sidebar', 'Outpatient', 'Clinic Notes', 'New Note']} />

<TaskHeader before="The patient must already be registered" time="5 minutes" after="A note saved as a draft, or signed and locked against the patient's chart" />

## 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](/hospital/front-desk/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:

| 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 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

<Steps>
  <Step title="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.
  </Step>

  <Step title="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".
  </Step>

  <Step title="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.
  </Step>

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

<Warning>
  **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.
</Warning>

## Who can do this

| Action                           | Who by default                                             | Governed by                                                                     |
| -------------------------------- | ---------------------------------------------------------- | ------------------------------------------------------------------------------- |
| Open **Clinic Notes** and write  | Any clinical staff member the Outpatient group is shown to | Role Navigation                                                                 |
| Sign and lock a note             | Clinicians                                                 | The **Sign and lock a consultation** permission where your hospital has set one |
| Countersign someone else's note  | Supervisors                                                | **Countersign a colleague's note**                                              |
| Unlock a signed note             | Whoever may sign                                           | Same permission as signing                                                      |
| Create and edit shared templates | Owners and managers, in practice                           | Role                                                                            |

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](/hospital/settings/role-navigation) is a convenience, not a security boundary. See [Permissions](/platform/team/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.

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

## Common issues

<AccordionGroup>
  <Accordion title="It will not save as final">
    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](/hospital/front-desk/patients).
  </Accordion>

  <Accordion title="It says the note is locked and cannot be modified">
    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.
  </Accordion>

  <Accordion title="My colleague's note is not appearing in Waiting on you">
    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.
  </Accordion>

  <Accordion title="Typing '/' does not bring up snippets">
    That shortcut works inside **Note Content** only, and needs at least one saved snippet. Create some under **Snippets** in the left rail.
  </Accordion>

  <Accordion title="The picker says 'Client' but we are a hospital">
    The picker keeps that label across every plan. It searches your patient list; the word on the button is the only difference.
  </Accordion>

  <Accordion title="I cannot find the note I wrote yesterday">
    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.
  </Accordion>
</AccordionGroup>

## FAQ

<AccordionGroup>
  <Accordion title="When should I use a clinic note instead of a consultation?">
    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.
  </Accordion>

  <Accordion title="What is the difference between Templates and Custom Templates?">
    **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.
  </Accordion>

  <Accordion title="Can two people write the same 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.
  </Accordion>

  <Accordion title="Does a note appear on the patient's chart automatically?">
    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.
  </Accordion>

  <Accordion title="Are notes included on our plan?">
    Yes. Every note feature — signing, locking, countersignature, templates, snippets and the AI writing tools — is included on Enterprise.
  </Accordion>
</AccordionGroup>

<StillStuck topic="clinic notes" />