Client notes

Clinical notes are free-form notes on a client's profile. A note can have formatted text, @mentions of colleagues, file attachments and voice recordings. Notes are on the client's Clinical Notes tab.

Notes are not linked to a specific appointment. Every note belongs to the client.

Open the Clinical Notes tab

1. In the sidebar, go to Clients → Client List.
2. Click the client.
3. Click the Clinical Notes tab.

You see the tab if your role can read notes. If you can see the tab but not the note editor, your role can't write notes or edit clients. Ask your clinic admin. See Staff roles.

Write a note

The note editor is always open at the top of the tab.

1. Click in Write your note here... and type your note.
2. Optional: format the text with the toolbar, or type / to open a menu of blocks (headings, lists, quote, code, divider, image) and your templates.
3. Optional: type @ and pick a colleague to mention them in the note.
4. Optional: add attachments or a voice note (see below).
5. Optional: click Private note or Sensitive (see Who can see a note).
6. Click Save Note.

Notes do not save automatically. If you leave the page before you click Save Note, the text is lost.

A note can be saved without text if it has an attachment or a voice note.

Add attachments

1. Click Attach file.
2. Choose one or more files.
3. Wait until each file finishes uploading.

• You can attach images, PDF, Word and Excel files, text and CSV files, audio and video.
• Each file can be up to 50 MB.
• If an upload fails, retry it or remove it. You can't save the note while an upload has failed.

Attach file and voice notes appear only when the File Storage module is on. See Document storage.

Record a voice note

1. Click Record voice note.
2. If the browser asks, allow microphone access.
3. Speak. The timer shows the recording length.
4. Click Stop recording. To discard it, click Cancel recording instead.
5. Listen to the recording. Click Use recording to keep it, or Re-record to try again.
6. Click Save Note.

• A recording stops by itself after 10 minutes.
• If you click Save Note while recording, MediSync stops the recording and saves it with the note.
• Voice notes are saved as audio only. MediSync does not transcribe them.
• Notes with a voice note show a Voice badge.

Use a template

Templates are pre-written note bodies.

1. In the note editor, type /.
2. Under Templates, pick a template. To filter the list, keep typing the template's slash command.
3. The template text is inserted into the note. Change it as needed.

You see your own templates, plus any System Templates your clinic has.

Manage your templates

1. In the sidebar, go to Clients → Note Templates.
2. Click New Template.
3. Enter a Name.
4. Enter a Slash Command. Use lowercase letters, numbers and hyphens only.
5. Optional: enter a Description.
6. Write the Template Body.
7. Click Save Template.

Your templates are listed under My Templates. Each template card has View, Edit and Delete actions. System Templates can be viewed but not changed.

Your templates are personal. Other staff can't see or use them. There are no clinic-wide custom templates.

Edit, sign or archive a note

Only the note's author can see the actions on a note. Point to the note and click the ⋯ button.

Sign a note

1. Click ⋯ on the note, then Sign note.
2. Read the message: "Signing finalizes this note. Once signed it is locked permanently and can no longer be edited. This cannot be undone."
3. Click Sign note.

The note shows a Signed badge. Only the author can sign a note.

You can't amend or add an addendum to a signed note. To correct it, write a new note.

See and restore earlier versions

Each time you save a change to a note's text, MediSync keeps the previous text as a version. Edited notes show an Edited badge with the number of versions.

1. Click the Edited badge, or click ⋯ and then History.
2. In Version history, select a version to read it.
3. To go back to it, click Restore this version, then confirm.

Restoring saves the current text as a new version, so nothing is lost. Only the author can restore a version, and only while the note is not signed.

Find a note

• Search notes… searches the notes on this client.
• The filter buttons show All, Archived or Private notes.

Who can see a note

When you turn on Private note, the editor reminds you: "Admins and owners can still see this note and its attachments."

A Sensitive note is hidden from everyone without the permission, including its author. If your role doesn't have View sensitive records and you mark a note as sensitive, it disappears from your view when you save.

Common problems

I can't see the Clinical Notes tab. Your role can't read notes. The tab shows "Clinical notes are only available to authorized staff." Ask your clinic admin.

There is no ⋯ button on a note. You are not the note's author. Only the author can edit, sign, archive or restore it.

Edit is missing from the ⋯ menu. The note is signed or archived. Signed notes can't be edited.

The Attach file and Record voice note buttons are missing. The File Storage module is off. Ask your clinic admin.

"Microphone access was denied." Allow microphone access for MediSync in your browser settings, then try again.

"Voice recording isn't supported in this browser." Your browser can't record audio. Try a different browser.

A note I saved has disappeared. Check the Archived filter. If it is not there, you probably marked it Sensitive and your role can't see sensitive records. A clinic admin can still see it.

Related

• Medical history
• Labs and documents