Editing a Clinical Note

When can I edit a clinical note?

Prior to a note being approved; a clinical note can be edited if:

• You have note creation rights
• Or you have note approver rights

After a note is approved, you can edit the note if

• You have the can edit approved clinical notes permission. This is designed for an administrator or compliance role and it's availability should be carefully considered.

When these conditions are met, an Edit button is available.

How can I edit a clinical note?

To Edit an existing clinical note:

1. Search for a patient.
2. Click Show.
3. In the Main Menu, click Clinical Notes.
4. Click Show for the clinical note you wish to edit.
5. Click Edit.
6. In the Text field, modify any content as needed.
7. In the Clinical Note Category field, select a different category if needed.
8. In the Case field, select a different case if needed.
9. Click Save Draft to save a draft version of the note for future editing; or,
10. Click Save Approved to finalise the clinical note. (A version number will appear , which is the number of times the Approved notes has been edited)

Disclaimer: Although the system allows you to edit a clinical note after approval, you should ensure you comply with any clinical best practice guidelines/legislation around editing existing clinical notes.

Auditing

See Clinical Note Audit Trail

Removing incorrect information

Where a note is wrong or irrelevant, you may wish to remove it in its entirety.

See Strike a Clinical Note