What is the Clinical Summary?

The Clinical Summary is a high-level text description of the patient's current status and care journey. It's displayed prominently across CAREFUL to give all team members quick insight into the patient's condition, pertinent diagnoses, and recent treatment.

The Clinical Summary is intended as an outline summary that conveys the most important clinical information about a patient. It may include:

• Pertinent diagnoses or problems
• Summary of recent treatment
• Key clinical observations
• Current care plan highlights

The Clinical Summary is dynamic and should be reviewed and updated regularly, particularly at each handover. This ensures the information remains current and relevant.

The Clinical Summary appears in three main locations:

1. Patient Profile — Displayed as a scrollable text box in the patient's main profile view
2. Team View — Shows in the patient list under the Patients tab for your team
3. My Patients View — Visible in your personal patient list

In all three locations, the Clinical Summary displays the latest update. If no summary exists yet, you'll see "Patient has no clinical summary" or "No current clinical summary."

Include here: Information relevant to all users caring for the patient across all teams. Since the Clinical Summary is visible to everyone who can view the patient, focus on universally important clinical details.

Don't include here: Team-specific information. For details relevant only to one team, Team Owners should instead set up handover categories.

For more structured patient information that needs to be captured consistently, Administrators can set up organisational fields.

Any user who can view the patient has permission to update the Clinical Summary. This includes:

• All members of teams caring for the patient
• All organisation Administrators

You do not need to be currently responsible for the patient to update the Clinical Summary.

When you create a new note, you're adding to the patient's notes history. The most recent note becomes the displayed Clinical Summary.

1. Navigate to the patient's profile
2. Click the kebab menu (three dots) in the header
3. Select New note
4. In the dialog that appears:
   • Applicable Date (required) — The date this note applies to
   • Title (optional) — A short heading for this note
   • New note (required) — Enter your clinical summary text
   • Attachments (optional) — Upload any relevant files
5. Click Submit

The new note will now appear as the patient's Clinical Summary throughout CAREFUL.

If you've just created a Clinical Summary note and need to make a quick correction, you can amend it — but only under specific conditions:

• You must be the original author of the latest note
• Less than 1 hour must have passed since you created it
• You can only amend the most recent note

If these conditions are met:

1. Navigate to the patient's profile
2. Click the kebab menu (three dots) in the header
3. Select Edit Latest Note
4. Update the text in the New update field
5. Click Submit

Your amended note replaces the previous version. After 1 hour has passed, or if someone else has since added a new note, you'll need to create a new note instead.

All Clinical Summary notes are preserved in the patient's history:

1. Navigate to the patient's profile
2. Click the Notes tab
3. You'll see a table showing all clinical summaries with:
   • Date created
   • Applicable date
   • Author
   • Attachments
   • Title and content

Click on any historical note to view its full details.

• Keep it current: Review and update the Clinical Summary at every handover or when the patient's status changes significantly
• Be concise: Focus on the most clinically important information that all team members need to know
• Use the 1-hour edit window wisely: If you spot a typo or error immediately after creating a note, you can quickly amend it without creating a duplicate entry
• Think cross-team: Write for an audience that includes all teams involved in the patient's care, not just your own team