Clinical notes and medical history
Write, complete and sign clinical notes, and keep the patient's conditions, medications, allergies and alerts as an append-only history.
Both live on the patient page of the PMS workspace, beside the chart.
Clinical notes
The Notes tab of the clinical record lists every note as a timeline, newest first, with the date on the left and the note's kind, author, time and state on its first line. A long note shows its first three lines; click the text to open it out. An addendum sits indented under the note it corrects, never on its own. The filters above the list narrow it to a state (All · Draft · Completed · Signed), an author, or a word in the text; a matching addendum keeps its parent on screen, so a draft addendum on a signed note still shows under Draft. Each row's actions are icons — Edit, Complete, Sign, Add addendum — shown only to the member who may take them.
A note has three states and never goes backwards:
| State | Who can change it | How |
|---|---|---|
| Draft | Its author | Edit the body freely |
| Completed | Nobody edits the body | Sign it, or write an addendum |
| Signed | Nobody | Addenda only |
To correct a completed or signed note, click Add addendum: a new note that refers to the original. The original never changes.
Dentists, hygienists and therapists author and sign; a nurse authors under supervision and never signs. Front-desk roles read notes and cannot write them.
Medical history
Conditions, medications and allergies are facts that are only ever added to. Correct writes a new row and archives the old one; Archive retires a fact that no longer applies. Archived rows stay visible, struck through, so the history reads as it happened. A fact marked From form came from a patient's own form after a clinician reviewed it.
Front-desk staff can record what a patient tells them at the desk; the clinician sees it on the next visit.
Alerts
Alerts are the banner everyone sees on the patient: an allergy, an infection-control note, a warning. Raise one with Raise alert and a severity; critical alerts pop up when the patient is opened. Archive an alert when it no longer applies. An alert marked as coming from an unreviewed form is provisional until a clinician reviews the form.