Write a clinical note

Here's how to document a visit with a structured SOAP note, then sign it to lock the record.

You'll document a complete patient visit in a single SOAP note, capturing the chief complaint, assessment, and plan all in one place. Signing the note locks it and ensures your clinical record is final and auditable.

Open the patient's chart from the Patients list.

Your patient's full history and prior notes are visible here, giving you the context you need as you document.

Start with the chief complaint — smart phrases like ".htnfu" expand into your saved templates to save you typing.

Smart phrases save time — type the abbreviation and it expands into your full template, so you document faster without sacrificing detail.

Document the plan — any orders and prescriptions you place from the note link back to it automatically.

Document the plan — orders and prescriptions you place from the note link back to it automatically.

Any orders or prescriptions you create from within the note are automatically linked back to it, keeping your clinical documentation and your actions in sync.

Click Sign note — signed notes are locked, and any later changes are simply recorded as addenda, so nothing is ever lost.

Click Sign note — signed notes are locked; later changes are recorded as addenda.

Once signed, the note is locked. Any changes after signing are recorded as addenda, preserving the original note's integrity for compliance and audit purposes.

What's next

Your signed note is now part of the permanent clinical record. If you need to add information later, you can create an addendum that references the original note.