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Write clinical notes

Updated

Clinical notes (evolutions) are the entries in the clinical history. Write them in the New Evolution panel of the chart or the consultation.

Who can use it: professionals at the patient's clinic, on every plan.

Step by step

  1. On the Clinical History tab, find the New Evolution panel on the right.
  2. Choose the Encounter type: Evolution, Diagnosis, Treatment and others.
  3. Optionally add Tags (for example, follow-up or post-op).
  4. Write the text. You can use bold, headings and lists. Type # to search medications and ICD-10 diagnoses (see Smart search with #).
  5. Choose the Status:
    • Draft: you can edit it for a while, 60 minutes from creation by default.
    • Final: it's closed and can't be changed.
  6. Save. To close a draft later, open it and select Finalize.
New Evolution panel with encounter type, status and tags

Search the clinical history

  • The left column groups entries by day, newest first.
  • Use Search clinical history... to search the text, and Filter by date for a day or a range.

Good to know

  • A final entry can't be edited or deleted. Use Copy as new to correct it in a new entry.
  • You can keep editing a draft with Edit draft while it's within the editing window. Only drafts can be deleted.
  • Files a patient uploads during a video call come in as drafts until the professional reviews them.
  • If the clinic restricts new tags, the ones you create stay pending approval until an administrator approves them (see Tag management).

Troubleshooting

Problem What to do
You can't save changes to a draft The editing window has passed. Copy it as new and correct it there.
You can't edit an entry It's final. Use Copy as new.
"New tags are restricted. Please contact admin." Use an existing tag, or ask your administrator to create it.
"Read only" Only professionals at the patient's clinic can write.