What are Notes?

Notes are clinical records attached to a patient's profile in CAREFUL. They allow healthcare professionals to document observations, clinical summaries, handover information, and important updates about a patient's care. Notes create a chronological record visible to all team members who share care of that patient.

Permissions required:

• You must be an authenticated organisational user (Administrator, Team Owner, or Clinical User)
• You must share at least one team with the patient to view or create notes
• You can only edit notes you created yourself, and only within one hour of creation

Each patient note contains:

• Applicable Date – The clinical date the note relates to (may differ from when you recorded it)
• Title (optional) – A short heading to identify the note (maximum 256 characters)
• Note content – Free-text clinical information
• Attachments (optional) – Images, documents, test results, or other files
• Author – The name of the staff member who created the note
• Date Created – When the note was recorded in CAREFUL

Notes appear in the Notes tab on a patient's profile, with the most recent notes at the top.

1. From the sidebar, select My Patients and click on the patient's name, or open the patient from a team patient list
2. Click the kebab menu (⋮) in the top right corner
3. Select New note from the dropdown
4. In the "Update notes" dialog:
   • Select the Applicable Date (defaults to today; you can choose dates up to 25 years in the past)
   • Enter a Title if you want to label the note (optional)
   • Type your clinical note in the New note field (required)
   • Attach files if needed by clicking Attachments and selecting your files
5. Click Submit

Your note appears immediately at the top of the Notes tab. All team members who share care of this patient can now see it.

You can edit a note only if:

• You created it yourself
• Less than one hour has passed since you created it

If these conditions are met:

1. Open the patient's profile
2. Click the kebab menu (⋮) in the top right corner
3. Select Edit Latest Note from the dropdown (this option only appears if you can edit)
4. In the "Amend latest notes" dialog, the New update field shows your current note content
5. Edit the text as needed
6. Click Submit

Important: You can only change the note content when editing. The title, applicable date, and attachments cannot be modified. If you need to make significant changes after the one-hour window, create a new note instead.

1. Open the patient's profile
2. Click the Notes tab

You'll see a chronological list of all notes for this patient, with the newest first. Each note shows:

• Date Created and Applicable Date
• Created by (author name)
• Title (if provided)
• Content (full text or "Show more.." link for structured notes)
• Attachments badge (if files were attached)

Viewing Attachments

If a note has attachments:

1. Click the kebab menu (⋮) on that note's row
2. Select View Attachments
3. A carousel opens showing all attached images and documents

Viewing Structured Notes

Some notes are created automatically when actions are completed or from structured forms. These show "Show more.." – click the link to view the full details in a dialog.

• Set the Applicable Date thoughtfully – If you're documenting something that happened earlier in the day (or on a previous shift), adjust the Applicable Date to reflect when the clinical event occurred, not when you're typing it up
• Use the Title field – A clear title like "Post-op review" or "Family discussion" helps colleagues scan the notes list quickly
• Edit window is short – You only have one hour to edit a note after creating it. If you spot an error later, create a new note with the correction
• Attachments stay visible – Uploaded images and documents remain accessible even after the one-hour edit window closes
• Notes are permanent – Once the edit window passes, notes cannot be deleted or modified. This ensures clinical record integrity and audit compliance
• All team members can see your notes – Any staff member who shares a team with the patient will see your note, so write clearly and professionally