Capture a clinical note
Write notes that hold up. From the calendar or the client record, with templates, smart chips, drag-and-drop images, and the ability to lock a note when it's final.
Open a note
Two routes. From the appointment: click the appointment on the calendar → Create note. This links the note to that session, which helps later when you're reviewing visit history. From the client record: open the client → New note (top right). Use this for non-session notes (phone calls, supervision, case discussions) where there's no calendar entry to attach to.
Use a template
Templates save you re-typing the same structure every session. From a note, click the file icon to open the template library, choose one, Select template, the template's structure drops in. One thing to know: insert the template first, then add content. If you've already written notes and then insert a template, it replaces what's there. Common starting points include SOAP and DAP, plus whatever custom ones you've built (Lesson 3.5), the Community library has many profession-specific options.
Smart chips, slash menu, and images
Smart chips (the pill-shaped icon next to a field) auto-populate from the client's profile: name, DOB, contact, custom fields. Drop them into a note instead of re-typing. The / command opens a quick-insert menu for lists, headings, images, form fields, and AI prompts. For visuals, drag images straight into the note from your desktop. Useful for body charts in physio, intra-oral photos in dental, range-of-motion diagrams.
Sign, share, and lock
Once the note is final, add your provider signature and lock it. Locking restricts who can edit the note, useful when you want a clear 'this is finalised' state for audit, supervision, or insurance claim trails. Share permissions (who else in your workspace can view the note) are set via the Share button before completing. If you later need to correct a locked note, follow your workspace's addendum process; don't unlock unless required.
Five note workflows worth standardising.
Same lessons, different professions. Adapt the one closest to yours.
SOAP template inserted first. Subjective via dictation, Objective from session observations, Assessment with smart chip linking to diagnosis, Plan with goals.
Body chart image dragged in, range-of-motion measurements, pain scale, treatment plan. Smart chip pulls client's prior session for comparison.
SOAP structure but with explicit BP/HR fields. Smart chip pulls allergies and current medications from the profile.
Tooth-by-tooth findings, intra-oral photos, recommended treatments, next-appointment notes.
No template, free-form note in the client record. Tagged 'supervision' so it doesn't appear in clinical history exports.
Can I create a note from a calendar appointment?
Yes, click the appointment on the calendar then Create note. This links the note to the appointment so it shows up under the session history.
Does inserting a template overwrite my existing notes?
Yes, if you've already started typing and then insert a template, the template replaces your text. Always insert the template first, then write.
What are smart chips?
Pill-shaped placeholders in the note editor that auto-fill with client data (name, DOB, contact, custom fields) when the note is rendered. Click the chip icon next to a field, select what to pull, and it pre-populates from the client's profile.
How do I lock a note?
Click the overflow toggle in the note module → Lock. Locking restricts editing access. Useful for finalising clinical records before claims, supervision, or audit.
Can I add images to a note?
Yes, drag-and-drop straight from your desktop. Body charts, intra-oral photos, range-of-motion diagrams all work. Image annotations are available for marking up.
What's the slash (/) command?
Type / in any note editor to open a quick-insert menu for lists, headings, images, form fields, and AI prompts. Faster than reaching for the toolbar.
Who can see my notes after I write them?
By default, you and any team members with documentation permissions for that client. Use Share in the note before completing to widen or narrow visibility. Locked notes still respect share permissions, locking is about editing, not viewing.