> ## 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 your first clinical note

> Document a visit from a template, from a blank page, or with the AI Note Taker, then sign and lock it.

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="Solo and Team" roles="Any clinical staff member" note="AI Note Taker, AI Rewrite and AI Autocomplete need a paid plan." />

This is step 1 of the [setup checklist](/practice/get-started), and the step most practices do first because it is the fastest way to see what the product actually does. Any saved note completes it — including a draft.

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

<TaskHeader before="Nothing. A client record is optional for a draft, and required before you sign" time="2 minutes" after="A saved note, either a draft you can come back to or a signed, locked record" />

## Pick how you want to write it

The **New Progress Note** page opens with three cards under **Quick Actions**:

| Card              | Use it when                                                                        |
| ----------------- | ---------------------------------------------------------------------------------- |
| **Use Template**  | You want a structured note — SOAP sections, an intake assessment, a treatment plan |
| **Blank Note**    | You want a free-text page with formatting and `/` commands                         |
| **AI Note Taker** | You want a note drafted from a recording or an uploaded file                       |

There is also a **Quick Note** card further down the same page for something short you want to save without leaving the dashboard.

## Write it from a template

<Steps>
  <Step title="Open the template editor">
    Select **Use Template**. To browse first instead, open **Templates** in the Notes sidebar — the pre-built library, with a **Use** button on every card.
  </Step>

  <Step title="Choose the template">
    Under **Select Template**, select **Choose a template...** and pick one. The card heading becomes **Progress Note - \{template name}** and the form fills with that template's sections — for a SOAP template these are **Subjective**, **Objective**, **Assessment** and **Plan**.
  </Step>

  <Step title="Attach the client">
    Use the **Client:** picker at the top of the form. It is optional for a draft, required before signing, and the AI Note Taker refuses to run without it.
  </Step>

  <Step title="Fill the sections">
    Type into each section. `/` opens the snippet menu anywhere in a note body, so a phrase you use constantly can be inserted rather than retyped — see [Note templates and snippets](/clinic/clinical/note-templates).
  </Step>

  <Step title="Save it">
    Select **Save Draft**. You get **Success** / "Draft saved successfully", and the note appears in **Recent Notes** with a **Draft** badge. The checklist step is now complete.
  </Step>
</Steps>

## Let the AI draft it

<Availability editions={['clinic']} plans="Starter and above" roles="Any clinical staff member" note="The AI Note Taker is not available on the free plan." />

Select **AI Note Taker** from the Quick Actions cards, or from either editor's toolbar. The sheet walks through **Select a Template**, **Customize Output** (**Note Tone**, **Speaker Mode**, **Custom AI Instructions**), then capture — **Live Recording** or **Upload File**.

<Warning>
  Recording a consultation requires consent. The sheet says so — "Always obtain verbal or written consent from all session participants before recording." — and that obligation is yours, not the product's.
</Warning>

While it works you see **Generating Notes ✨**, then **Notes Ready!** with the draft and a reminder that it is *generated in memory only* until you select **Apply to Form**. Applying it inserts the text under an `--- AI Generated
Note ---` marker and toasts "Review and save."

<Note>
  AI output is a draft for you to check, never a record on its own. Read every section, correct what is wrong, and only then save or sign. More in [AI clinical notes](/clinic/clinical/ai-notes).
</Note>

## Sign and lock it

A draft completes the checklist step; signing is what makes it a clinical record.

<Steps>
  <Step title="Select Sign & Lock">
    In any editor, select **Sign & Lock**. The sheet summarises **Note**, **Client** and **Date**.
  </Step>

  <Step title="Add your signature">
    Under **Provider Signature**, either **Typed** or **Draw**.
  </Step>

  <Step title="Accept the attestation and sign">
    Tick the attestation confirming the note is accurate and that signing locks it, then select **Sign & Lock**.
  </Step>
</Steps>

<Warning>
  A signed note cannot be edited — the tooltip on the button says "Locked notes can't be edited afterwards". Owners and managers can **Unlock Note** if a correction is genuinely needed, and both the signing and the unlocking are recorded.
</Warning>

## Check it worked

* The note is listed under **Recent Notes** with a **Draft** or **Final** badge.
* The **Get Started** checklist shows **Write your first clinical note** as complete, with no refresh needed.
* If you signed it, the editor shows **Read-Only (Locked)** and **Export** (or **Export PDF**) produces the PDF version.

<AuditNote action="Opening, signing and exporting a note" />

## If something goes wrong

<AccordionGroup>
  <Accordion title="Export is disabled">
    Exporting needs a saved note — "Please save the note as a draft before exporting." Save the draft first, then export.
  </Accordion>

  <Accordion title="The AI Note Taker will not start">
    It needs a client selected on the note. If the button is greyed out rather than complaining, your plan does not include it — see [Change your plan](/platform/plans/change-plan).
  </Accordion>

  <Accordion title="A template has the wrong sections for my specialty">
    Copy the closest pre-built template and edit it under **Custom Templates**. See [Note templates and snippets](/clinic/clinical/note-templates).
  </Accordion>

  <Accordion title="I signed a note with a mistake in it">
    Ask an owner or manager to **Unlock Note**, correct it, and sign again. Do not write a second note describing the error — the unlock and the re-signature are both on the record.
  </Accordion>

  <Accordion title="The checklist step has not ticked">
    It completes on the first saved note of any kind. An AI draft you never selected **Apply to Form** on was never saved, so it does not count.
  </Accordion>
</AccordionGroup>

<StillStuck topic="clinical notes" />