Introduction
The clinical summary is a free-text field where you can document clinical notes, diagnoses, and observations about a patient. You can create new notes with attachments or quickly amend recent notes if needed within one hour of creation.
Before You Start
You must have access to the patient (share at least one team with them) to update their clinical summary. No special role is required – any team member with access can add or amend notes.
Steps
Creating a New Clinical Note
- From the sidebar, click My Patients to view your patient list
- Click on the patient row to open their profile
- The patient's Profile tab displays by default, showing the clinical summary field
- You have three ways to add a new note:
- Click directly on the clinical summary field (which shows a pencil icon)
- Click the New note button above the tab bar
- Click the kebab menu (⋮) in the top navigation and select New note
- The "Update notes" dialogue box appears with the following fields:
- Applicable Date – when the note applies to (defaults to today, optional)
- Title – a brief heading for the note (optional)
- New note – the main clinical summary text (required)
- Attachments – upload supporting files if needed (optional)
- Fill in the clinical summary text in the New note field
- Optionally complete the other fields (date, title, attachments)
- Click Submit
- The dialogue closes automatically and the patient's clinical summary field updates with your new note
If the patient has no existing clinical summary, the field displays "Patient has no clinical summary" until you add the first note.
Amending Your Latest Note (Within 1 Hour)
If you created the most recent clinical note and it's less than one hour old, you can amend it:
- Navigate to the patient's profile (following steps 1-2 above)
- Click the kebab menu (⋮) in the top navigation
- Select Edit Latest Note (this option only appears if you're eligible to amend)
- The "Amend latest notes" dialogue opens with your existing note text pre-populated
- Edit the clinical summary text as needed
- Click Submit
- The dialogue closes and the patient's clinical summary updates with your amended text
Note: When amending, you can only edit the text content. You cannot change the applicable date, title, or add new attachments. To add attachments or change metadata, create a new note instead.
Viewing Clinical Summary History
All clinical notes are preserved in the patient's history:
- On the patient's profile, click the Notes tab
- A table displays all clinical summaries with columns for Date Created, Applicable Date, Created by, Attachments, Title, and Content
- Each row has a kebab menu (⋮) with options to view attachments or edit the latest note (if within the 1-hour window)
Tips
- Quick updates: Click directly on the clinical summary field for the fastest way to add a note
- Amendment window: You have exactly one hour from creation to amend your own note – after that, you'll need to create a new note instead
- Copy and paste: If you want to build on a previous note, copy the existing text before creating a new note, as the new note dialogue starts blank
- File attachments: Attach supporting documents (images, PDFs, etc.) when creating new notes – this helps provide complete clinical context
- Audit trail: All clinical notes are permanently logged, including amendments, so you have a complete audit trail of patient observations