What is a Clinical Summary?

Introduction

The Clinical Summary is a high-level text description of a patient's current status. It provides a quick overview of the patient's condition, pertinent diagnoses, recent treatment, or other relevant information that all care team members should know.

What is the Clinical Summary?

The Clinical Summary is designed to be dynamic and should be reviewed for accuracy at each handover. It appears prominently in several locations:

• Patient Profile: Displayed at the top of the patient's record
• My Patients View: Shows in a dedicated "Clinical summary" column (toggle visibility using the "Show clinical summaries" filter checkbox)
• Team View: Visible in the patient list for quick reference
• Notes Tab: Full history of all clinical summary updates with timestamps and authors

Since the Clinical Summary is visible to all users who can view the patient, information should only be included if it's relevant to everyone. For team-specific information, team owners should set up handover categories instead. For more structured data, administrators can configure organizational fields.

Who Can Update the Clinical Summary?

Any user who can view the patient has permission to update the clinical summary, including:

• All members of teams caring for the patient
• All administrators

You do not need to be currently responsible for the patient to update their clinical summary.

How to Create a New Clinical Summary

Before You Start

No special permissions required. You just need to be able to view the patient.

Steps

1. Navigate to the patient's profile page
2. Click the action dropdown menu (three dots)
3. Click the New note button (clipboard icon)
4. The Update notes dialog appears with a form containing:
   • Applicable Date (optional): Select the date this note applies to
   • Title (optional): Add a descriptive title for this note
   • New note (required): Enter the clinical summary text
   • Attachments (optional): Attach supporting files if needed
5. Enter your clinical summary in the New note field
6. Click Submit
7. The dialog closes and the patient's clinical summary is immediately updated
8. The new entry appears in the patient's Notes tab history

Expected Result

• The new clinical summary appears in the patient profile
• The "Clinical summary" column in patient tables shows the updated text
• A new entry appears at the top of the Notes tab with timestamp, your name, and the content
• An audit trail entry records the update

How to Amend the Latest Clinical Summary

If you created the most recent clinical summary and less than 1 hour has passed, you can amend it instead of creating a new entry.

Before You Start

• You must be the original creator of the latest clinical summary
• Less than 1 hour must have passed since you created it

Steps

1. Navigate to the patient's profile page
2. Click the action dropdown menu
3. If you're eligible to amend, you'll see an Edit Latest Note button (pencil icon)
4. Click Edit Latest Note
5. The Amend latest notes dialog opens with the existing content pre-populated:
   • Applicable Date: Previously entered date (if any)
   • Title: Previously entered title (if any)
   • New note: The existing clinical summary text
6. Make your changes to any of the fields
7. Click Submit
8. The dialog closes and the existing clinical summary entry is updated in place

Expected Result

• The latest clinical summary is modified (not duplicated)
• The Notes tab shows the amended entry with updated content
• An audit trail entry records the amendment

Viewing Clinical Summary History

Steps

1. Navigate to the patient's profile page
2. Click the Notes tab
3. A table displays all clinical summary entries with columns:
   • Date Created: When the note was created
   • Applicable Date: The date the note applies to (if specified)
   • Created by: The user who created the note
   • Attachments: Any files attached to the note
   • Title: The note title (if specified)
   • Content: The clinical summary text
4. The latest entry appears at the top
5. Click on any row to view the full details in a read-only dialog
6. Click on attachments to view or download them

Toggling Clinical Summary Visibility

In the My Patients view, you can control whether the clinical summary column appears.

Steps

1. Navigate to My Patients from the sidebar
2. Locate the filter controls in the top navigation area
3. Find the Show clinical summaries checkbox
4. Check the box to show the "Clinical summary" column in the patient table
5. Uncheck the box to hide the column

When the column is visible, each patient row shows their current clinical summary or "No current clinical summary." if none exists.

Tips

• Keep it current: Update the clinical summary whenever significant changes occur in the patient's condition
• Be concise: The clinical summary should be a high-level overview, not a detailed progress note
• Review at handover: Make it a practice to review and update the clinical summary during patient handovers
• Use the 1-hour amendment window: If you spot a typo or need to clarify something shortly after creating a note, use Edit Latest Note instead of creating a duplicate
• Attach supporting documents: Use the attachments feature to include relevant scans, reports, or other documentation
• Check the Notes tab: Review the full history to understand the patient's clinical journey over time

Related Features

• What is a Handover? - Learn about transferring patient responsibility
• How to Manage Handover Categories - Set up team-specific structured data
• Managing Organizational Fields - Configure structured patient data fields
• Patient Profile - Explore other patient profile features