# Record findings and sign a note (/docs/en/learn/clinician-record-and-sign)



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 [#why]

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](/docs/en/get-started/saved-recorded-signed) explains the idea in general. This lesson makes you do it once.

## How it works [#how]

Anna de Vries has her blood pressure taken during her follow-up. Her doctor types `/` in the note and chooses **Blood pressure**.

### Four states [#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 [#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 [#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 [#try-it]

Use the open "Learning visit" on **Sam Testpatient** from the previous lesson.

1. In the note, type `/` and choose **Blood pressure**. Enter 128 and 82. Press Enter.
2. Type `/` again, choose **Heart rate** and enter 72. Press Enter.
3. 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.
4. Choose **Add 2 to the record**. Both blocks now show when they were recorded.
5. Choose **Sign**. Check that the panel counts 2 entries in the record. Choose **Sign** again.
6. Find the line that starts with "Signed", followed by your name and the time.
7. Open **Vitals** on the **Record** page. Both readings are there. Open **Visits** and check that the visit is signed.
8. 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 [#check]

1. You typed "BP 130/85" as plain text in a note. Is that reading in the record?

<details>
  <summary>
    Answer
  </summary>

  No. Plain text is only saved in the note. Add a **Blood pressure** block and record it.
</details>

2. Two drafts are waiting and you choose **Record 2 & sign**. In which order does Salisan work?

<details>
  <summary>
    Answer
  </summary>

  It records the drafts, saves the note, then seals the signed version. If a step fails, nothing is signed.
</details>

3. After signing, you notice a wrong value in a recorded reading. What do you do?

<details>
  <summary>
    Answer
  </summary>

  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](/docs/en/guides/clinical-records#withdraw).
</details>

## Next [#next]

Continue with [Record a consultation and write it up](/docs/en/learn/clinician-dictation). For the full steps, see [Visits and notes](/docs/en/guides/visits#sign).