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How to write a clinical note without AI or dictation

๐Ÿ‡ฌ๐Ÿ‡ง ๐Ÿ‡ฎ๐Ÿ‡ช ๐Ÿ‡ฆ๐Ÿ‡บ ๐Ÿ‡ณ๐Ÿ‡ฟ ๐Ÿ‡จ๐Ÿ‡ฆ 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

๐Ÿšจ 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.

Screenshot 2026-03-02 at 12.35.32.png

๐Ÿ“ 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.

๐Ÿ’ก 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 - Lock your note

  • Once you are happy you have captured all the information about the appointment, you must click 'Lock' to complete your note.

  • This step ensures the original note is saved safely against the patients history.

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  • After clicking 'Sign and lock' you will see that the note is now marked with who and when it was signed and locked by.

  • You can still make amendments after signing and locking your note using the 'Add amendment' button at the top of your note.

image showing sign and locked information and add amendment button

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