Draft Clinical Note

What is a Draft Clinical Note?

Draft Clinical Note in Noterro refers to a clinical note that is in progress and has not yet been finalized. Draft notes can be edited and saved multiple times until they are ready to be finalized. This feature allows practitioners to make adjustments and ensure accuracy before locking the note.

Why do Healthcare Providers Create Draft Clinical Notes?

Healthcare providers create Draft Clinical Notes to capture initial observations, assessments, and plans for Patient care during or immediately after a Patient encounter.

How are Draft Clinical Notes Different from Finalized Clinical Notes?

Draft Clinical Notes are preliminary and may be incomplete, while finalized clinical notes are comprehensive, accurate, and reviewed for completeness before being considered part of the Patient's permanent medical record.

What Information is Typically Included in Draft Clinical Notes?

Draft Clinical Notes may include initial Patient assessments, provisional diagnoses, treatment plans, and any immediate actions taken during the Patient encounter.

How do Draft Clinical Notes Contribute to Patient Care?

Draft Clinical Notes contribute to Patient care by documenting initial findings and plans. These notes can guide ongoing treatment, communicate with other healthcare providers, and ensure continuity of care.

Key Features of Draft Clinical Notes in Noterro:

1. Editable:
   • Draft notes can be edited as many times as needed. This flexibility allows practitioners to update and refine the information before finalizing it.
2. Autosave:
   • Draft notes are automatically saved as you adjust them, ensuring no information is lost during editing.
3. Finalization:
   • Once a draft note is finalized, it becomes locked and cannot be edited. However, you can add an addendum to a finalized note if additional information needs to be included.

Important Points to Consider

• Reverting Finalized Notes:
  • You have 7 days to revert a finalized note to a draft if further edits are needed. After 7 days, finalized notes cannot be modified.
• Addendums:
  • You can create an addendum to add information to a finalized note. This ensures all relevant information is included without altering the original finalized note.

Benefits of Draft Clinical Notes in Noterro:

• Accuracy:
  • Allows practitioners to ensure the accuracy and completeness of clinical notes before finalizing them.
• Flexibility:
  • Provides the flexibility to make changes and updates as needed, accommodating the dynamic nature of clinical documentation.
• Efficiency:
  • Autosave functionality ensures that no information is lost, streamlining the documentation process.