Create and sign a clinical note
Available to
Clinician and other authorised care users.What this task does
Captures a structured or narrative note for the patient, facility, encounter, and note type.
Steps
- Open the patient record or Healthcare > Clinical Care > Notes.
- Create a note and select the patient, facility, encounter, note type, author, and clinical date/time.
- Enter the clinical content using the locally approved format.
- Save the draft while it is still under preparation.
- Select Submit when the note is ready for clinical signing.
- The authorised clinician reviews the completed note and selects Sign when it is accurate and complete.
What happens next
A signed note becomes part of the longitudinal record. If a correction is required, create an attributable amendment rather than changing the signed text. The visible note progression is Draft, Submitted, and Signed; an amendment creates a new draft version and preserves the signed record being amended.