Saved, recorded and signed

A visit note passes through four states, and each tells your colleagues something different. The words you type are saved automatically. A finding you capture in the note is a draft until you add it to the record. Once added, it is an entry in the patient's record. When you sign, the visit closes and the note is sealed as a version. Saved text is not in the record, and a record entry is not a signature.

Follow one note

Dr Jansen sees Anna de Vries for a follow-up and starts a visit.

1. She types that Anna had a rash after penicillin as a child. The words save as she types. The record still holds no allergy.
2. She presses / and captures an Allergy and a Blood pressure reading, and finishes each with Done. Both are drafts inside the note.
3. She chooses Add 2 to the record. Both become entries in Anna's record.
4. She chooses Sign. The visit closes and the note is sealed.

Saved text

The note body saves automatically. The indicator reads Saving… and then Saved. If it reads Couldn't save — retrying or Unsaved changes, your latest words have not reached Salisan yet, so wait for Saved before you leave the page.

Saved means the words are stored in the note. Salisan does not read your sentences to create entries, so "allergic to penicillin" typed as text creates no allergy.

Drafts

Press / in a visit note to capture a block such as an Allergy, Diagnosis, Medication or a vital sign (blood pressure, heart rate, respiratory rate, oxygen saturation, temperature or weight). Fill in the block and choose Done. It collapses to a line marked with a hollow diamond.

A draft lives only in the note. It is saved with the note and is not in the record. When a note mixes recorded entries and drafts, a draft shows Not recorded. A block missing required values is unfinished and is not counted. Finish it or choose Remove.

Entries in the record

Choose Add … to the record. The number is how many ready drafts will be written. Each one becomes an entry on the patient's Record page and in the pages that use it, such as vitals. Recorded lines show a solid marker and the time.

The result is reported per entry. If one fails, it shows Couldn't record and Try again, and the others stay recorded. Choosing the button again does not duplicate entries that already exist.

Entries outlive the note. Remove from note on a recorded block only detaches it, and the entry stays in the record. Fix a wrong value by correcting the entry in the record. A withdrawn entry stays readable and struck through. See Clinical records.

On the patient's Record page there is no draft step. A block there has a Record button and writes the entry when you choose it.

Signed

Only visit notes are signed. Choose Sign to open the panel Sign this note. It shows how many entries are already in the record, how many drafts will be recorded when you sign, and the version it will seal.

Confirm with Sign, or Record 2 & sign when drafts are waiting. Choose Not yet to leave the visit open. Salisan then works in order: record every ready draft, save the note, seal it. If a step fails, the visit stays open and a message says why. Entries that were recorded stay recorded, and you can sign again.

You must finish or remove unfinished blocks first, and you need write access to the patient's clinical record. After signing, a line on the note reads Signed, with your name and the time. The visit leaves To sign. You can also sign a note with no drafts left from the To sign queue with Sign & next. A signed visit cannot be reopened. See Sign the note and To sign.

After signing

A signed note is not locked (see Amend a signed note). You can still edit it, and the note then shows Edited after signing with the time. See what changed lists the versions and what moved since the signed one. The original stays recoverable, and each change is dated.

Adding more drafts to a signed note opens Record to a signed note with a warning that the edit will show as edited after signing. Entries already recorded appear read-only in the signed note, marked Part of the signed note. Correct them in the record.

What this means for you

• When you see Saved, your words are safe. Nothing is in the record or signed yet.
• Capture every finding you want to keep as a block, then add it to the record before you sign.
• Before you rely on a colleague's note, check for the Signed line. Without it, the visit is still open.
• Booking an appointment or sending a form is a separate act with its own status. It is not part of the signature.

Next: Visits and notes for the full steps, and The Agent and you for drafts the Agent proposes.