Clinical documents

Purpose

Structured, specialty-specific notes and reports (OPD notes, examinations, assessments, discharge notes…) written on templates of the specialties enabled for your clinic, electronically signed and kept with a full audit trail.

Who uses it

• Practitioners (write, sign, co-sign, amend)
• Nurses / assistants (drafts, if the role allows)
• Admins (templates — see Templates)

Prerequisites

• The Clinical documents module is enabled for the clinic and at least one specialty pack is active.
• Your role has the needed permissions: view clinical documents to open them, create to start one, sign to sign, amend for amendments/addenda, void to void.
• Your practitioner profile has your qualification and registration number (they are printed in the signature block).

Step by step

Find documents

1. Open Clinical Documents in the menu (/app/clinical-documents). You see the newest documents of your branch.
2. Each row shows the template, the status chip (Draft, In review, Final, Amended, Voided), the document number once signed, the patient and the dates. Restricted marks sensitive documents.
3. Addenda are listed under the document they belong to. Amends / Superseded by links move along an amendment chain.
4. Filter by Status, Template, Specialty and From / To dates (both days included). The list reloads a moment after you stop changing the filters. If you see The search stopped early…, press Load more to keep searching older documents.
5. Click a patient name to open that patient's timeline (/app/patients/<id>/documents): the same list grouped by day, with a New document button for that patient.

Write a new document

1. Press New document (from the list or from the patient timeline).
2. If no patient is selected yet, type at least two letters of the name, phone number or patient ID and pick the patient.
3. Choose a template: type to search (name, code or specialty, in English or Hindi), use ↑ ↓ and Enter, or click. Templates are grouped by specialty; your Recently used templates are shown first.
4. Tick Mark as restricted before choosing the template if the document is sensitive.
5. The draft is created and the editor opens. Patient details (name, age, visit date, latest vitals…) are filled in automatically where the template asks for them.

Fill and sign

1. Type into the fields. Changes are saved automatically — the status line shows Saving… / All changes saved.
2. Use All normal on a section, smart phrases (.ros + Space) and Copy forward from the previous document (see the shortcuts below).
3. Press Sign or Ctrl+Enter. If something is missing you are taken to the first problem and a summary lists everything to fix.
4. After signing the document is Final: it gets a document number (e.g. CDOC-20260926-A1B2C3), is locked and shown read-only. If the template needs a co-signature it goes to In review instead.

Co-sign

1. Open a document that is In review. If you submitted it, you see Waiting for co-signature by another practitioner.
2. A different practitioner sees This document is waiting for your co-signature and a Co-sign button. Co-signing makes the document Final; both names appear in the signature block.

Correct a signed document

• Amend — press Amend, give a reason (3–500 characters) and edit the new draft copy that opens. When you sign it, the original is marked Amended and links to the new version. Pressing Amend again while a copy is open takes you to that copy.
• Add addendum — press Add addendum and confirm; a short note document opens, attached to the original. Sign it like any document.
• Void — press Void and give a reason. The document is marked entered in error and kept for audit. If an amendment is still open you are asked to sign or void the amendment first (a link takes you there).

History and print

• History opens a side panel with every lifecycle event (created, edited, submitted for co-signature, signed, amendment started, amended, addendum added, voided), who did it and when.
• Print opens the print view of the document (drafts print with a DRAFT watermark).

When something goes wrong

Message	What it means / what to do
Document not found	The document does not exist or you are not allowed to see it (e.g. a restricted patient).
This document was changed somewhere else	Someone saved the same draft on another screen. Press Reload.
This document is locked	It was signed or voided meanwhile; it can no longer be edited.
Field messages after Sign	The server rejected some values; fix the highlighted fields and sign again.
A different practitioner must co-sign	You submitted this document yourself; ask a colleague to co-sign.

If you leave the page while changes cannot be saved (for example offline), the browser asks before discarding them.

How signing and corrections work

• Draft — saved as you type; required fields are only enforced when you sign. If a colleague saved the same draft meanwhile you are asked to reload (no silent overwrite).
• Sign — the document is electronically signed: it gets a document number, a snapshot of the patient, practitioner (name, qualification, registration no.) and clinic details, and a content fingerprint. It can no longer be edited. Pressing Sign twice never creates two signatures.
• Co-signature — some templates need a second practitioner: after your signature the document waits In review until a different practitioner co-signs it.
• Amend — opens an editable copy of a signed document; when the copy is signed it replaces the original, which stays in the record marked Amended.
• Addendum — a short signed note attached to a signed document (the original stays unchanged).
• Void — marks a document entered in error (a reason is required). Nothing is ever deleted.
• Restricted documents are visible only to their author (and users explicitly granted access to restricted records).
• Every opening of a document is recorded in the access log (who, when, which patient) — see Compliance.

Editor shortcuts and tips

Action	How
Open the command menu (jump to a section, “All normal”, insert a phrase, copy forward, sign)	Press / (when not typing in a box) or Ctrl+K (⌘K on Mac)
Expand a smart phrase	Type . + the shortcut, e.g. .ros, then press Space or Tab
Jump to the next blank *** in a phrase	Tab or F2 (F2 starts again from the top)
Mark a section normal	All normal button on the section header (fills only empty fields)
Sign	Ctrl+Enter (⌘Enter) or the Sign button

• Copy forward fills only empty fields from the previous document. Copied values are highlighted until you Confirm them (or edit them); signing waits until they are confirmed. Vitals and patient details are never copied — they are always taken fresh.
• Manage your own smart phrases under Clinical Documents → Smart Phrases (/app/settings/smart-phrases).
• Formatting in rich-text boxes: **bold**, _italic_, lines starting with - or 1. become lists. HTML is not allowed.
• The pages work on tablets: the toolbar wraps, dialogs open as bottom sheets and every action is reachable by keyboard.

Printing, PDF, verification & sharing

Open a document and choose Print / PDF / Share (address /app/clinical-documents/<id>/print). The preview is exactly what will be printed — the same layout is used for paper, PDF and shared links.

Action	What happens
Print	Opens the document in a new window and starts your browser's print dialog. Page numbers ("Page 2 of 3"), your letterhead and the QR code are added automatically. If nothing happens, allow pop-ups for this site.
Print language	Choose English or हिन्दी for the printed labels (the clinical text is printed as entered).
Download PDF	Available a few moments after signing, once the PDF is ready ("PDF is being prepared…" until then). PDFs are only offered for the current signed version; an amended or voided document can still be printed and is marked AMENDED / VOIDED across the page.
Share	Creates a link that expires after 1–30 days (default 7). Tick Require a one-time code to make the recipient enter a code sent to the patient's registered mobile — this is always required for restricted documents. Copy the link or press Send on WhatsApp (the message contains only your facility name and the link).
Revoke	In the Share dialog, Revoke stops a link immediately. Links also stop working when the document is voided, and are revoked automatically after 10 wrong codes.

• Drafts print with a large DRAFT mark and "Not signed — draft copy"; only signed documents carry a document number, a QR code and "Electronically signed by … on …".
• Verifying a printout: anyone can scan the QR code (or open the printed "Verify at" address). The page shows the document number, title, your facility, the signing date and whether it is Valid, Replaced by a newer version or Voided — never the patient's name or any clinical details.
• Audit: every print, PDF download, share and every opening of a shared link is recorded in the access log (a shared-link view is recorded against the link, not a staff member).
• One-time codes for shared links: at most 5 codes a day per link, one per minute; a code is valid for 5 minutes and works once. If a patient is marked restricted later, their existing links start asking for a code automatically.
• Nothing about the document is stored in the browser; closing the tab removes it.

FAQ

Why do I not see a document my colleague mentioned? Lists show your branch only (unless your role is clinic-wide), and restricted documents only appear for authorised staff.

Can I delete a document? No. Void it with a reason; the record stays for audit.

Why does “Load more” appear with a filter that matched few documents? To stay fast the search checks a limited number of documents at a time; Load more continues it.