Notes
Definition
Clinical Notes is the space where staff record and exchange written notes about a patient. Care groups the messages into titled discussions, so different topics stay separate. You find Clinical Notes in the Notes tab, which shows a panel called Discussions.
Clinical Notes is a Care feature for staff collaboration. Care does not map Clinical Notes to an FHIR R5 resource.
Key Attributes
A discussion groups related messages under one title. A message is one entry in a discussion.
| Components | What it captures |
|---|---|
| Title | The subject of the discussion. The title holds up to 255 characters. |
| Message | The text of one entry in a discussion. The text supports Markdown formatting. |
| Author | The staff member who wrote the message. Care records this for you. |
| Time | The date and time of the message. Care records this for you. |
A discussion holds a title only. A message holds text only. This module has no status, no category, and no coded value.
Encounter discussions and patient discussions
Care keeps two separate spaces for discussions:
- Encounter discussions belong to one encounter. You see them in the Notes tab of that encounter.
- Patient discussions belong to the patient. You see them in the Notes tab of the patient profile.
The two lists never overlap. A patient discussion never appears inside an encounter. An encounter discussion never appears on the patient profile.
Order of discussions and messages
Care lists the discussions with the most recent first. Inside a discussion, the newest message appears at the bottom. Care loads older messages 20 at a time as you scroll up.
Permanence
Care shows no way to delete a discussion. Care shows no way to delete a message. After you send a message, the message stays in the discussion.
Attachments and mentions
Care does not support file attachments in messages. Care does not support user mentions in messages.
Who can see and write
| Action | Permission | Roles |
|---|---|---|
| See encounter discussions and messages | Can Read encounter related clinical data | Doctor, Nurse, Admin, Facility Admin |
| Start an encounter discussion, or post a message in one | Update Encounter related clinical data | Doctor, Nurse, Admin, Facility Admin |
| See patient discussions and messages | Can view clinical data about patients | Staff, Doctor, Nurse, Admin, Facility Admin |
| Start a patient discussion, or post a message in one | Can Update a Patient's data | Staff, Doctor, Nurse, Administrator, Admin, Facility Admin |
If the encounter is closed, you cannot start a discussion in it. You also cannot post a message in it. Care treats an encounter as closed when its status is Completed, Cancelled, Discontinued, or Entered in error.
Note: No deployment setting changes how Clinical Notes behaves.
Related
- Flow: Start a discussion
- Flow: Post a message to a discussion
- Flow: Find discussions for a patient or an encounter
- Concept: Encounter