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How to write a clinical note without AI or dictation

🇬🇧 🇮🇪 🇦🇺 🇳🇿 🇨🇦 UK, ROI, AU, NZ, CA - Documenting clinical notes in the clinical sidebar for each appointment without using dictation of AI summaries

Written by Amber Morris

🚨 Important - This article is only relevant to sites using the new notes experience currently rolling out across sites.

How to write a clinical note

Step 1 - Open the clinical note side panel

  • Clinical notes are saved against each appointment on the patients treatment plan.

  • To start writing your notes click 'Create note' or click on the 'Open clinical notes sidebar' button across the top of the patient's current appt.

📝 Please note - Only Level 2 practitioners and above can create, edit and update clinical notes.


Step 2 - Select a template

This is an optional step.

  • Click 'Template' or use type '/' and the name of your template to add your preferred template.

💡 Top Tip - Although optional, using templates to guide your note-taking enables you to created structured notes every time.


Step 3 - Type your notes

  • Start typing your notes in the editor.

  • You can highlight text or use the '/' menu to add formatting to your note as you type, such as bold or italics.

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Step 4 - Review your note

  • Once you are happy you have captured all the information about the appointment, you must click 'Complete' to mark your note as reviewed.

💡 Top Tip - if you don't have time to review your note during the appointment, you can use Tasks to help you find incomplete notes at the end of the day.

  • This step ensures it is clear that you have completed and reviewed your note in the patients history

  • After clicking 'Mark as reviewed' you will see that the note is now marked with who and when it was reviewed.

  • You can still make amendments after reviewing your note.

Please note - if you would like to write a treatment item note you can do this by following this guide.

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