Capture a clinical note
Write notes that hold up. From the calendar or the client record, with templates, smart data chips and drag-and-drop images, then sign and complete the note when it's final.
- An appointment to open the note from, if you want the note linked to the session (lesson 3.1)
- A template picked before you start typing, if you're using one (lesson 3.7)
Open a note
Two routes in:
- From the appointment: click it on the calendar, then Create note. This links the note to the session, which helps later when you're reviewing visit history.
- From the client record: open the client, then New note (top right). Use this for non-session notes (phone calls, supervision, case discussions) with no calendar entry to attach to.
Use a template
In the note's toolbar, open Insert and click Use template. Pick from Recently used, or Choose from template library, then click Use template. In a brand-new note you can also pick from Recent templates under Suggested actions.
One thing to know: insert the template first, then write. A template replaces everything already in the note, including any form fields you've filled in, and it doesn't ask first. SOAP and DAP are common starting points, plus whatever you've built (Lesson 3.7) or found in the Community library.
Smart data chips, slash menu, and images
- Smart data chips fill in details for you, such as the client's or practitioner's name, appointment dates and the last diagnosis code. Add them from + → Add smart data chips in the toolbar, or type / and look under Smartchips.
- / opens the quick-insert menu: lists, tables, headings, images, form structures and codes.
- Images drag straight in from your desktop: body charts in physio, intra-oral photos in dental, range-of-motion diagrams. Hover an image to edit, crop or caption it.
Diagnoses go in the note's Medical coding tab: search ICD-10, or click Add ICD-10 code manually.
Sign and complete
When the note is final, click Sign and complete. It adds your signature and locks the note in one step, which gives you a clear finished state for audits, supervision and insurance claims. If you need to correct it later, click Unlock.
If you're supervised, you'll see Sign or Request review instead, and your supervisor signs and completes the note.
To give a client or contact access to the note, use Share in the note's ⋯ menu.
Tick these off in your own workspace before moving on.
Five note workflows worth standardising.
Same lessons, different professions. Adapt the one closest to yours.
SOAP template inserted first. Subjective via dictation, Objective from session observations, Assessment with a smart chip for the last diagnosis code, Plan with goals.
Body chart image dragged in, range-of-motion measurements, pain scale, treatment plan.
SOAP structure with explicit BP and HR fields, plus an allergies field added from Form structures.
Tooth-by-tooth findings, intra-oral photos, recommended treatments, next-appointment notes.
Written as normal, then Request review. The supervisor reads it and clicks Sign and complete.
Can I create a note from a calendar appointment?
Yes, click the appointment on the calendar then Create note. This links the note to the appointment so it shows up under the session history.
Does inserting a template overwrite my existing notes?
Yes. A template replaces everything already in the note, including filled-in form fields, and it doesn't ask first. Always insert the template first, then write.
What are smart data chips?
Placeholders that fill in details for you, such as client or practitioner names, appointment dates and the last diagnosis code. Add them from + → Add smart data chips in the toolbar, or type / and look under Smartchips.
How do I lock a note?
Click Sign and complete. It signs and locks the note in one step. To change it later, open the note and click Unlock.
Can I add images to a note?
Yes, drag them straight in from your desktop. Body charts, intra-oral photos and range-of-motion diagrams all work. Hover an image to edit (draw on it), crop or caption it.
What's the slash (/) command?
Type / in the note editor to open a quick-insert menu for lists, tables, headings, images, smart data chips, form structures and codes. Faster than reaching for the toolbar.
Who can see my notes after I write them?
Your team sees notes according to their permissions for that client. Share, in the note's ⋯ menu, is for giving a client or contact access as a viewer, responder or editor. No client or contact can see a note until you share it.