Writing and signing clinical notes
Draft notes, use templates, and lock a note once it is finalized.
Start a note
From an appointment, open Notes and choose a template. Templates pre-populate sections so you can focus on content.
Notes autosave as you type. You can return to a draft at any time before signing.
Using templates
Templates keep your documentation consistent and speed up routine sessions. Start from a built-in template or save your own for reuse.
Custom templates can reflect your preferred note format, such as SOAP, DAP, or a progress note structure.
Locking a note
Once a note is complete, sign and lock it. Locked notes become part of the permanent record and require an addendum to change.
Use an addendum rather than unlocking when you need to add information after signing.