Overview

Clinical Notes allow you to document patient visits, assessments, treatments, and outcomes. Phyzioline supports multiple note types including SOAP notes, evaluations, progress notes, and discharge summaries.

Accessing Clinical Notes

URL: /clinic/clinical-notes
Navigation: Sidebar → Clinical Notes

Creating a Clinical Note

1. Click Create New Note
2. Select patient
3. Choose note type:
   • SOAP - Subjective, Objective, Assessment, Plan
   • Evaluation - Initial patient evaluation
   • Progress - Progress update
   • Discharge - Discharge summary
   • Re-evaluation - Follow-up evaluation
4. Select specialty template (if applicable)
5. Fill in the note sections
6. Add diagnosis codes (ICD-10)
7. Add procedure codes (CPT)
8. Review and save

SOAP Note Structure

Subjective (S)

• Patient-reported symptoms
• Chief complaint
• History of present illness
• Patient's perspective

Objective (O)

• Physical examination findings
• Measurements (ROM, strength, etc.)
• Objective observations
• Test results

Assessment (A)

• Clinical interpretation
• Diagnosis
• Progress assessment
• Clinical impression

Plan (P)

• Treatment plan
• Goals
• Next steps
• Follow-up instructions

Voice-to-Text Feature

You can use voice-to-text to quickly dictate notes:

1. Click the microphone icon
2. Start speaking
3. Text will appear in real-time
4. Review and edit as needed

Note Statuses

• Draft - Being written, not finalized
• In Review - Under review
• Signed - Finalized and signed
• Locked - Cannot be edited

Signing Notes

1. Complete the note
2. Review all sections
3. Click Sign Note
4. Confirm signature
5. Note becomes locked and official

Best Practices

• Write notes immediately after patient visit
• Be specific and detailed
• Use proper medical terminology
• Include all relevant codes
• Sign notes promptly to finalize