Overview
Clinical Notes provides access to all documented patient encounters, including visit notes, progress notes, assessments, and other clinical documentation. This comprehensive view helps providers understand the patient’s care history and make informed clinical decisions.Note Types: Clinical notes include provider visit notes, nursing notes, progress notes, assessment findings, and care coordination documentation.
Accessing Clinical Notes
From Patient Chart
Quick Access from Schedule
Types of Clinical Notes
Provider Visit Notes
Documentation from provider encounters:| Component | Description |
|---|---|
| Visit Date | When the visit occurred |
| Provider | Who conducted the visit |
| Visit Type | Routine, follow-up, urgent, etc. |
| Chief Complaint | Reason for visit |
| Assessment | Clinical findings and diagnoses |
| Plan | Treatment plan and orders |
| Signature | Provider signature and timestamp |
Progress Notes
Ongoing observations and updates:Daily Progress
Day-to-day patient observations
Nursing Notes
Nursing staff documentation
Medication Notes
Medication-related observations
Care Coordination
Communication and coordination notes
Assessments
Formal clinical assessments:| Assessment Type | Description |
|---|---|
| Initial Assessment | Comprehensive intake evaluation |
| Annual Assessment | Yearly comprehensive review |
| Skin Assessment | Skin integrity and wound evaluation |
| Fall Risk Assessment | Fall risk evaluation |
| Pain Assessment | Pain level and management |
| Cognitive Assessment | Mental status evaluation |
| Nutritional Assessment | Dietary and nutrition status |
Incident Documentation
Reports of incidents and follow-up:| Document | Description |
|---|---|
| Incident Report | Initial incident documentation |
| Follow-up Notes | Post-incident monitoring |
| Investigation Notes | Incident investigation details |
| Resolution | How incident was resolved |
Viewing Notes
Note List View
The notes list displays:| Column | Description |
|---|---|
| Date | When the note was created |
| Type | Category of note |
| Author | Who wrote the note |
| Summary | Brief preview of content |
| Status | Draft, Signed, Amended |
Opening a Note
Click on any note to view the full content:Filtering and Searching Notes
Filter Options
| Filter | Options |
|---|---|
| Date Range | Last 7 days, 30 days, 90 days, 1 year, custom |
| Note Type | Visit notes, progress notes, assessments |
| Author | Filter by specific provider or staff |
| Status | Signed, draft, amended |
Search Notes
Use the search bar to find notes containing:- Specific diagnoses
- Medications
- Keywords
- Provider names
Understanding Note Status
| Status | Meaning | Actions Available |
|---|---|---|
| 📝 Draft | Note not yet signed | View, edit (by author) |
| ✅ Signed | Note completed and signed | View, print, add addendum |
| 📎 Amended | Addendum added to signed note | View full history |
| 🔒 Locked | Note locked per retention policy | View only |
Note Details
Note Header
Each note displays:| Field | Description |
|---|---|
| Patient Name | Patient the note is for |
| Date/Time | When note was created |
| Author | Who created the note |
| Note Type | Category of documentation |
| Facility | Where care was provided |
| Status | Current note status |
Note Body
The content section includes:Subjective
Patient-reported information (chief complaint, symptoms)
Objective
Provider observations (exam findings, vitals)
Assessment
Clinical assessment and diagnoses
Plan
Treatment plan and follow-up
Note Footer
| Field | Description |
|---|---|
| Signature | Electronic signature of author |
| Sign Date | When note was signed |
| Addendums | Link to any addendums |
| Print/Export | Options to print or export |
Actions on Notes
View Note
Click to open and read the full note content.Print Note
Add Addendum
For signed notes, add additional information:Note History
Viewing Note History
For amended notes, view the complete history:History Display
| Element | Description |
|---|---|
| Original Note | First version of the note |
| Addendum 1, 2… | Subsequent additions |
| Timestamps | When each entry was made |
| Authors | Who made each entry |
Using Notes for Clinical Decisions
Before a Visit
Key Information to Look For
| Category | Look For |
|---|---|
| Recent Changes | New diagnoses, medication changes |
| Hospitalizations | Recent admits/discharges |
| Lab Results | Recent test results and trends |
| Specialist Notes | Consult recommendations |
| Care Plan Updates | Changes to care plan |
| Patient Concerns | Documented patient issues |
Troubleshooting
Cannot find a specific note
Cannot find a specific note
Possible causes:
- Note is outside the date filter
- Note type filter is excluding it
- Note is in draft status
Note content appears incomplete
Note content appears incomplete
Possible causes:
- Note is still a draft
- Display is collapsed
- Loading issue
Cannot print notes
Cannot print notes
Possible causes:
- Browser popup blocker
- Print permission issue
Notes from other providers not visible
Notes from other providers not visible
Possible causes:
- Notes not yet synced
- Access permissions
- Notes in different system