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Write and sign a clinical note

Document an encounter by writing a note in the patient's chart. Notes save as drafts until you sign them; signed notes become part of the permanent record.

Before you start​

You need note-writing permission. Prescribers and Residents/Interns write and sign independently; Medical Students, Medical Assistants, and Scribes write under supervision and their notes require attestation by a provider. Open the patient's chart first (see Find a patient and open their chart).

Steps​

  1. In the chart navigation rail, go to Documentation → Documentation Hub.
  2. Under New Note, click a template tile: History & Physical, Progress Note, Consult Note, Admission Note, Discharge Summary, or Procedure Note. The note editor opens with that note type pre-selected.
  3. Write the note in the text area. You can change the note type from the dropdown at the top of the editor. A word and character count appears above the text area.
  4. Finish one of two ways:
    • Save draft — the note is stored as a draft (marked preliminary) that you can sign later.
    • Sign & Submit — the note is finalized and added to the record. This button is disabled until the note has content.
  5. To review or sign notes later, go to Documentation → Progress Notes in the chart rail. Draft notes carry an amber Draft badge; signed notes show a green Signed badge.
  6. Select a draft note and click Sign in the preview pane to finalize it. You can also Copy the note text or Print it from the same pane.

Tips / Troubleshooting​

  • If the visit is in progress, new notes are automatically linked to the current encounter.
  • If the template tiles are grayed out, your role cannot create notes for this patient — the page will say so beneath the tiles.
  • Drafts do not auto-save. If you close the editor without clicking Save draft, your text is lost.