Clinical notes allow you to document each patient consultation, creating a permanent record of findings, diagnoses, and treatment plans.
- After completing a consultation, navigate to the Appointment Detail page
- Click Add Clinical Note
- Complete the note form:
- Subjective — patient's reported symptoms and history
- Objective — examination findings and observations
- Assessment — diagnosis or differential diagnosis
- Plan — treatment plan, investigations, referrals
- Follow-up — any required follow-up arrangements
- Click Save
- Open the appointment record
- Click Edit Clinical Note (only available if you are the author)
- Make your changes
- Click Save
An audit trail of all changes is maintained.
Good clinical notes should include:
- Date and time of consultation
- Presenting complaint and history
- Relevant examination findings
- Diagnosis or clinical impression
- Treatment prescribed (if any) with medication name, dose, quantity
- Any referrals or investigations requested
- Follow-up arrangements
- GP notification status (see GP Notifications guide)
- Write notes immediately after each consultation
- Be specific — avoid vague terms like "feeling unwell" without detail
- Record why a treatment was chosen, not just what was prescribed
- If the patient declines treatment or a referral, document the discussion
- Notes are legal documents — write as if they will be read by the CQC or in a court of law