ClinicalPatient Management
Clinical Notes Tab
Document a clinical encounter using structured SOAP content, with medications, vitals, and lab results attached.
Starter+
The Clinical Notes tab on a patient's profile is where you write and review clinical documentation for that patient — there's no separate Clinical Notes area outside a patient's profile.
Creating a note
A note requires a type and a title:
- Type: Consultation, Medication Review, Follow-up, Adverse Event, or Other
- Title: a short free-text label
- Content: structured the same way as a visit note — Subjective, Objective, Assessment, Plan (SOAP) — all optional, but at least filling in the relevant sections makes the note actually useful to whoever reads it later
What else you can attach to a note
- Medications — link one or more of the patient's medications directly to this note
- Vital signs — record vitals as part of the encounter
- Lab results — attach lab data referenced during the encounter
- Recommendations — a free-form list
- Attachments — files relevant to the encounter
- Follow-up — flag the note as needing follow-up and set a target date
Priority and confidentiality
Every note has a priority (Low / Medium / High, defaulting to Medium) and can be marked confidential — confidential notes are still visible to your team but flagged as sensitive.
Tags and search
Notes can be tagged freely, and both the title and every SOAP section are full-text searchable — useful once a patient has a long history.
Next steps
- Visit History & SOAP Notes — a related but separate record type, used for visit-specific documentation with file attachments
- Medications Tab