Record findings and sign a note
Turn findings in a note into entries in the record, then sign the note and understand what the signature seals.
After this lesson you can put findings from a note into the patient's record and sign the note. It takes about 15 minutes. You need write access to the patient's clinical records.
Why it matters
Writing "BP 128/82" in a note does not create a reading in the record. Colleagues and the rest of the workspace read the record, not the words of your note. Signing is the other half: it seals the note as the version you stand behind.
Knowing which of the two you have done is the most useful habit in a visit. The overview Saved, recorded, signed explains the idea in general. This lesson makes you do it once.
How it works
Anna de Vries has her blood pressure taken during her follow-up. Her doctor types / in the note and chooses Blood pressure.
Four states
| State | What it means | Where it lives |
|---|---|---|
| Saved text | The words of the note reached the server | The note only |
| Draft block | A finished block that nothing has written yet | The note only |
| Recorded entry | The finding was written to the record | The patient's record |
| Signed | A version of the note was sealed with your name | The note |
Draft first, then record
Anna's doctor fills in the systolic and diastolic values and presses Enter, or chooses Done. Nothing is written yet. The block collapses into a line with a hollow marker. Once the note holds recorded entries or is signed, drafts also show Not recorded.
At the top of the note the button Add 1 to the record appears. The number is how many drafts are ready. Choose it, and the block becomes a recorded line with the time it was recorded. The reading now appears under Vitals on the Record page.
If one draft fails, it shows its own error and Try again. The others stay recorded. A recorded block cannot be deleted from the note. To undo it you withdraw it, as in the previous lesson.
Sign the note
Choose Sign. The panel Sign this note appears inside the page. It shows how many entries are in the record and how many drafts will be recorded when you sign. If drafts are waiting, the button reads Record 2 & sign. Choose Not yet to go back.
Signing records ready drafts, saves the note and seals a version, in that order. If any step fails, nothing is signed and the visit stays open. Findings that were already recorded stay recorded.
Afterwards the note shows a line that starts with "Signed", followed by your name and the time. You can still edit a signed note. The signed version is kept, and the note shows Edited after signing. See what changed compares the two. Recorded entries inside a signed note are read-only there. Correct them on the Record page.
Try it
Use the open "Learning visit" on Sam Testpatient from the previous lesson.
- In the note, type
/and choose Blood pressure. Enter 128 and 82. Press Enter. - Type
/again, choose Heart rate and enter 72. Press Enter. - Look at the top of the note. It reads Add 2 to the record. Open Sam's Record page in another tab: Vitals is still empty.
- Choose Add 2 to the record. Both blocks now show when they were recorded.
- Choose Sign. Check that the panel counts 2 entries in the record. Choose Sign again.
- Find the line that starts with "Signed", followed by your name and the time.
- Open Vitals on the Record page. Both readings are there. Open Visits and check that the visit is signed.
- Optional: add a word to the signed note. Find Edited after signing, then choose See what changed.
Signing cannot be undone. Here that is safe, because Sam is a test patient.
Check yourself
- You typed "BP 130/85" as plain text in a note. Is that reading in the record?
Answer
No. Plain text is only saved in the note. Add a Blood pressure block and record it.
- Two drafts are waiting and you choose Record 2 & sign. In which order does Salisan work?
Answer
It records the drafts, saves the note, then seals the signed version. If a step fails, nothing is signed.
- After signing, you notice a wrong value in a recorded reading. What do you do?
Answer
Open the reading on the Record page and correct it, or withdraw it if it should never have been recorded. The words of the signed note do not change. See Clinical records.
Next
Continue with Record a consultation and write it up. For the full steps, see Visits and notes.