How to Update Clinical Summary

Introduction

Clinical summaries provide a comprehensive record of a patient's current status and care notes. You can either create a new clinical summary entry with full details (including attachments and metadata) or quickly amend the most recent entry.

Before You Start

• You must be a member of the team managing the patient
• You must have an active patient profile open
• For amendments: Only the original author can amend their own clinical summary entries, and only within the configured time deadline

Steps

To Create a New Clinical Summary Entry

1. Navigate to the patient profile you want to update
2. Locate the clinical summary section and click to open the update dialog
3. The "Update notes" dialog appears with the following fields:
   • Applicable Date: Select the date this clinical summary applies to (defaults to today, allows dates up to 25 years in the past, no future dates allowed)
   • Title: Enter an optional title in the field (placeholder: "Enter title")
   • New note: Type your clinical summary in the multi-line text area (placeholder: "Enter note")
   • Attachments: Click to upload any relevant files
4. If uploading attachments, wait for all files to finish uploading before submitting
5. Review your entries to ensure the date is complete (year, month, and day must all be selected)
6. Click the "Submit" button
7. The dialog closes automatically and the patient profile refreshes with your new clinical summary entry

To Amend the Latest Clinical Summary

1. Navigate to the patient profile with the clinical summary you want to amend
2. Click the option to amend the latest clinical summary
3. The "Amend latest notes" dialog appears showing:
   • The current clinical summary (read-only display)
   • A "New update" field where you can enter your amendment
4. Type your amendment text in the "New update" field (it will auto-focus when the dialog opens)
5. Click the "Submit" button
6. The dialog closes automatically and the patient profile updates with your amended clinical summary

To View Clinical Summary History

1. From the patient profile, click to view the clinical summary history
2. A dialog opens with the clinical summary's title as its heading
3. Review the "Form Data" table showing all details of the clinical summary
4. Check the "Associated Actions" table to see any linked care tasks
5. Close the dialog when finished reviewing

Tips

• Use the full "Update notes" option when you need to attach files or specify a particular date
• Use "Amend latest notes" for quick corrections or additions to recent entries
• The applicable date defaults to today but can be backdated if documenting historical information
• All clinical summary updates are automatically logged in the audit trail
• Multiple team members can view clinical summaries, but only the original author can amend their entries
• File uploads must complete before you can submit - the Submit button will be disabled during uploads
• If you see a validation error about an incomplete date, ensure you've selected the year, month, and day

Related Features

• How to View Patient Audit Log: Track all changes made to a patient's record
• How to Add Actions for a Patient: Create care tasks associated with clinical summaries
• How to Hand Over Patient Responsibility: Transfer patient care when updating clinical status