Sometimes human error enters into your note taking. Clinical notes are a history of patient care and therefore must be completely accurate. As long as a clinical note has not been signed, you can make changes or corrections to the note.
Watch this video to learn how to edit a clinical note. (Duration: 1:20)
Additional Information
- Edits can be made to the providers, the date, and to the text of the note.
- You can add notes from a template. They will be inserted where the text cursor is positioned.
- You cannot delete a clinical note after it has been signed.
- To work with notes that have already been signed, see Adding an Addendum to a Signed Clinical Note.