๐จ 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.
๐ 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.
๐ก Top Tip - Although optional, using templates to guide your note-taking enables you to create structured notes every time. Take a look at our best practice guidance for optimising your templates for use with AI.
Step 3 - Dictate your notes
Click the 'Record' button on the clinical note sidebar to start recording and dictating your notes. Your speech will appear under the transcript window and will be saved here against the note for future reference.
You can open and close the transcript using the 'Transcript' button along the top of your sidebar.
๐ Please Note - If you haven't tried dictating with AI notes before we recommend trying AI notes with a test patient first. Take a moment to try different microphones, accent settings, and locations across your practice to see what gives you the best results.
You can manually type notes into the editor as well as speaking your notes.
There is no need to format your speech, simply speak naturally or to your template and the AI will handle the formatting for you when it generates a summary.
There are multiple stop buttons to use when you need to stop your recording.
From the side bar itself
From the appointment on the treatment plan
From the top of the patients record
๐ก Top Tip - Use your template as a script, to say everything you need to about each patient. Take a look at our guide on how to speak to AI for the best outcomes every time.
Step 4 - Generate summary
Once you have finished dictating your notes, click 'Generate' button at the top of the note sidebar and the AI will take over and create a structured, formatted note, capturing all the important details from both your transcript and your typed notes.
If you have a template selected it will use this as a guide to the structure your transcript into your note.
๐จImportant - You should always double-check your AI summaries for accuracy. Since AI tools can misinterpret information, always take a moment to verify that the generated notes correctly reflect what was dictated.
You can click 'Generate' as many times as needed, so even if you generate your note and then add more details via dictation or typing - you can click 'Generate' again to restructure your output.
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.
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.
