Templates that match how you assess
Every note is written on a template. Set up your own under Manage → Note templates: initial assessment, SOAP follow-up, post-operative knee, vestibular, sports injury. A new practice starts with a set for physiotherapy that you can change any way you like.
A note copies its template's layout when you start writing, so improving a template next month never rewrites what you wrote today.
Body charts
Mark the area of pain or symptoms on a body chart inside the note. Marking a chart is always part of note-taking; owners can also design the charts the practice offers.
Notes that save themselves
A note saves itself as you type, with no Save button to forget. If the connection drops, the note keeps a local copy on your device and saves it when you are back online. A note is often the only record of a consultation that has already happened, so it must never depend on a button.
Draft, then signed
A note is a draft while you write it. When it is finished, sign it and it locks. After that, corrections are amendments, dated additions that sit with the note while the original stands. A note that can be quietly rewritten is worth little in a complaint, an insurer dispute or a court.
The dashboard's Uncompleted notes card lists visits you have seen with nothing written. It shows only your own.
Cases
A case is one episode of care: a knee, a shoulder, a back. Notes, goals, outcome measures, letters and care plans belong to the case, and its funding, such as a WorkCover claim, can sit on the case too. Close a case with a discharge summary when the episode ends.
Letters from the case
Write to the GP or specialist from the case, on your letterhead, and email it from the record. See GP and referrer letters.
Who can read clinical notes
Clinical notes are for the people providing care. A reception, accounts or marketing login can never open them, and no setting changes that. See patient privacy and security.
Nothing clinical is deleted
A record can be archived to take it off the active list, but every note is kept. Australian law keeps clinical records for years, and the software keeps them for you.
Frequently asked questions
Can I write SOAP notes in Clinidiary?
Yes. Set up a SOAP template, or any layout you use.
What happens if the internet drops while I am writing?
The note keeps a local copy and saves it when you are back online.
Can I edit a signed note?
No. You add a dated amendment, and the original stands.
Can reception read clinical notes?
No. Reception logins can never open clinical notes.