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Version: 3.1

Clinical Notes

A clinical note in Care is written commentary about a patient. The care team uses notes for narrative, hand-offs, and discussion, in their own words. Care groups notes into discussion threads, so one topic stays together as a conversation. A note does not replace structured clinical data, such as a condition, an allergy, or an observation.

Key Attributes​

ComponentsWhat it captures
Discussion titleA short label for the topic of the discussion, for example "Treatment Plan"
PatientThe patient that the discussion is about
EncounterThe encounter that the discussion belongs to, when a user starts the discussion from the encounter
MessagesThe individual entries that care team members post in the discussion
ParticipantsThe people who posted a message in the discussion
Edit historyThe earlier text of each message, with the author and the time of the change

Discussions​

A discussion is one conversation about a topic. Care shows discussions in two places:

Where you open notesWhat you see
The Notes tab of a patientDiscussions that belong to the patient, and not to a single encounter
The Notes tab of an encounterDiscussions that belong to that encounter

A patient discussion stays with the patient over time. An encounter discussion stays with one visit. Care suggests a set of discussion titles, such as "Treatment Plan", "Medication Notes", "Care Coordination", "General Notes", "Patient History", "Referral Notes", and "Lab Results Discussion". You can also enter your own title. Two discussions of the same patient cannot have the same title.

Messages​

A message is one entry in a discussion. Many people can post messages in the same discussion. Care shows the author, the time, and the message text. Care formats the message text as rich text.

Edit history​

A note is an auditable record. If the author edits a message, Care keeps the earlier text. Care adds the earlier text, its author, and the time of the change to the history of the message. Only the author of a message can edit that message. Nobody can erase what the team wrote before.