Clinical Notes

Create comprehensive clinical documentation using SOAP format with optional AI assistance.

Overview

The clinical notes system provides a structured SOAP (Subjective, Objective, Assessment, Plan) format for documenting patient encounters. Notes include vital signs tracking, customizable templates, and optional AI-powered voice transcription for Premium users.

Creating a Clinical Note

Visit Information (Required)

  • Visit Date - When the encounter occurred
  • Note Type - Office Visit, Procedure, Follow-up, Phone Call, or Telehealth
  • Chief Complaint - Brief description of why the patient is being seen

SOAP Sections (Configurable)

Each section is optional and can be enabled/disabled in Settings > Notes.

S - Subjective

Patient's description of symptoms, medical history, and review of systems. Document what the patient tells you about their condition.

O - Objective

Clinical findings from physical examination, vital signs, and test results. Document what you observe and measure.

A - Assessment

Your clinical judgment, diagnosis, or differential diagnosis. Document your conclusions about the patient's condition.

P - Plan

Treatment plan, medications prescribed, follow-up instructions, and patient education. Document what actions will be taken.

Auto-Save Protection

Notes are automatically saved every 5 seconds while you work. If you accidentally close the browser, your draft will be restored when you return to continue editing.

Vital Signs

Record patient vitals as part of the clinical note. All fields are optional.

Blood PressureSystolic / Diastolic mmHg
Heart RateBPM
Temperature°F or °C
Respiratory RateBreaths per minute
Weightlbs or kg
Heightin or cm
Oxygen SaturationSpO2 %
BMIAuto-calculated

Signing Notes

Important: Notes Cannot Be Edited After Signing

Once a note is signed, it becomes a legal medical record and cannot be modified. If corrections are needed, you must create an amendment to the original note.

Only staff members with signing permissions (typically doctors and nurses) can sign clinical notes. The signing process:

  1. Complete all required sections of the note
  2. Review the note for accuracy
  3. Click "Sign Note" button
  4. Confirm the action in the dialog
  5. Note is locked and timestamped with your signature

Creating Amendments

If you need to correct or add information to a signed note, create an amendment:

  1. View the signed note
  2. Click "Create Amendment"
  3. Document the corrections or additions
  4. Provide a reason for the amendment
  5. Sign the amendment

The amendment is linked to the original note, maintaining a complete audit trail.

Voice Recording (Premium)

Premium users with the AI Medical Scribe add-on can use voice recording to create notes:

How It Works

  1. Click "Start Recording" during a patient encounter
  2. Speak naturally - the system captures the conversation
  3. Click "Stop Recording" when finished
  4. Audio is automatically transcribed using medical-grade AI
  5. Review and edit the transcript as needed
  6. Process with AI to extract clinical actions

AI-Powered Transcription

Transcription is powered by Deepgram's Nova-2 Medical model, optimized for healthcare terminology. The system includes speaker diarization to distinguish between provider and patient speech.

AI Action Extraction (Premium)

After transcription, Claude AI analyzes the encounter and suggests actions:

Schedule Follow-up

"See me in 2 weeks" → Creates appointment suggestion

Update Medical Record

"Allergic to penicillin" → Suggests adding allergy

Create Task

"Order lab work" → Creates follow-up task

Send Document

"Sign the consent form" → Queues document for signature

Each suggested action includes a confidence score and the relevant transcript excerpt. You can approve, modify, or reject each suggestion before execution.

Customizing Note Templates

Configure which sections appear in your clinical note forms:

  1. Go to Settings > Notes
  2. Toggle each section on or off:
    • Vital Signs
    • Subjective
    • Objective
    • Assessment
    • Plan
  3. Click "Save Preferences"

Note: All visible sections remain optional - you can save notes without filling in every section.

Viewing Patient Notes

Access clinical notes from multiple locations:

  • Patient Record - Click on a patient, then go to the Clinical Notes tab
  • Recent Notes - The 10 most recent notes appear on the patient overview
  • Note Detail - Click any note to view the full SOAP documentation

Each note displays the visit date, note type, author, signature status, and all recorded information.