Clinical Notes
Clinical Notes is where encounter documentation lives: create notes from Practice → Notes Templates (and provider SOAP templates when used), edit drafts, complete or send for review, approve/lock, add addenda, fax, mark as error, and download PDF. Notes can pull lab/imaging results into the note for documentation—they do not place orders (use Orders). Uploaded files belong under Documents.
What Clinical Notes Is For
Official visit/encounter notes for the patient. Templates come from Practice → Notes Templates. Statuses commonly include Draft, Complete, Review, and Approved/Locked depending on your workflow.
Where and When to Use It
Open chart → Clinical Notes after or during a visit to document care. Use Documents for PDFs and uploads. Use IntelliMed AI only for assistance—finish the legal note here.
How It Works
Create a note from a template, edit content, Save as Draft while work continues, then Complete or Send for Review. Reviewers Evaluate when your process uses review. Locked/approved notes are restricted; Add Addendum for later corrections when allowed. Mark as Error for notes that should not stand. Download PDF for sharing or records.
How to Create, Edit, or Correct
Create Note → choose template → edit → Save & Draft or Complete / Send for Review. Edit only while your status and permissions allow. After lock, use Add Addendum rather than silently rewriting history. Fax eligible notes when Fax Clinic Notes permission and outbound fax setup exist. Delete is highly restricted (often Super Admin).
Faxing a Clinical Note
When the note status allows and you have fax permission, use Send fax / send clinical note by fax, choose referring provider and fax number, then send. Password-protected PDFs may fail—export an unprotected copy. RingCentral fax settings are often required for outbound send.
Usage with Lab and Imaging
Order tests under Orders → Lab Orders / Imaging Orders (catalogs from Practice Lab Settings and Imaging Categories). When results are on chart Labs/Imaging, template sections for laboratory/imaging results can auto-fill into the note. You can also attach a clinical note when faxing an order package. Full practice setup and end-to-end cases: Practices → Notes Templates, Lab Settings, and Imaging Categories help.
Common Note Usage Cases
(1) Draft during visit → Complete. (2) Document → Send for Review → reviewer Approves. (3) After approve → Add Addendum for new info. (4) Download PDF or Fax to outside provider. (5) Labs/imaging ordered same visit → results return → pull into note sections → Complete. (6) Mark as Error when a note should not stand. Practice template setup and favourites: Practices → Notes Templates.
Common Issues
Cannot create: missing Clinic Notes add permission or templates/options not set up under Practices → Notes Templates. Cannot edit: note locked—use Addendum. Looking for order buttons: go to Orders. Looking for uploads: Documents. Fax greyed out: status, permission, or fax setup. AI draft not a finished note: finish in Clinical Notes.