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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.
| Components | What it captures |
|---|---|
| Discussion title | A short label for the topic of the discussion, for example "Treatment Plan" |
| Patient | The patient that the discussion is about |
| Encounter | The encounter that the discussion belongs to, when a user starts the discussion from the encounter |
| Messages | The individual entries that care team members post in the discussion |
| Participants | The people who posted a message in the discussion |
| Edit history | The earlier text of each message, with the author and the time of the change |
A discussion is one conversation about a topic. Care shows discussions in two places:
| Where you open notes | What you see |
|---|---|
| The Notes tab of a patient | Discussions that belong to the patient, and not to a single encounter |
| The Notes tab of an encounter | Discussions 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.
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.
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.
- Flow: Start a note discussion
- Flow: Add a note message
- Concept: Patient
- Concept: Encounter
- Reference: Notes