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Creating and Editing Case Notes

The Case Note edit screen allows Team Members to create, edit, and finalise clinical documentation for a patient. This screen provides structure, flexibility, and connection to linked appointments and templates.

🔧 Screen Breakdown

👤 Case Note Overview (Top Section)

This section displays important patient and author information:

  • Patient Name, DOB, and MRN – automatically displayed at the top.

  • Clinician – the name of the Team Member editing the note.

  • Discipline – the professional discipline of the note author (e.g. Clinical Psychologist).

  • Linked Appointment – a dropdown to connect this note to a past or upcoming appointment. Selecting one ensures better record keeping and helps display the note within relevant parts of the platform.

📌 Tip: Only one appointment can be linked to a note, and only appointments for this patient will appear in the dropdown.

🧾 Case Note Entry (Bottom Section)

Here you’ll complete the body of the Case Note.

  • Template – Shows which template has been applied (if any). Click Select Template to open the list of available templates.
    ⚠️ Applying a template will permanently overwrite any existing content in the note.

  • Title – The title of your note. You can rename it from the default "Case Note" to something more descriptive (e.g. “Initial Psychology Consult”).

  • Case Note Text Field – A rich text editor where you can write your note. Supports:

    • Formatting (bold, italic, bullet points, checklists, etc.)

    • Tables

    • Hyperlinks

    • Code snippets (for technical notes)

    • Markdown-friendly styling

🚨 Warning on Template Replacement

When you click Select Template, a warning will appear:

“Applying a template will override all existing content in this case note. Any text you have previously entered will be permanently replaced.”

Please ensure you want to apply a template before entering note content.

✅ Action Buttons

  • Cancel – Closes the note without saving changes.

  • Save & Exit – Saves your note in In Progress state, allowing you to return and edit later.

  • Save & Finalise – Marks the note as Finalised. This locks in the content (unless unlocked) and includes it in the permanent clinical record.

  • Delete – Removes the note entirely. This option is only available for In Progress notes and may be restricted based on permissions.