Concepts/Clinical Notes: Difference between revisions

{{Doc header

|type=concept

|domain=clinical

|title=Clinical Notes

|order=13

|introduced=3.0

|fhir=Clinical Notes

|concept=Concepts/Observation

|reference=References/Notes

}}

A '''clinical note''' in Care is the care team's written commentary about a patient — the place where staff record narrative, hand-offs, and discussion in their own words rather than in structured fields. Notes are organized into threads, so a single topic stays together as a conversation instead of scattering across the record.

== What it represents ==

In Care's FHIR-aligned model, clinical notes map to the '''Communication''' resource — running written exchanges about a patient. A note thread holds:

* '''A subject''' — every thread is anchored to one patient, and optionally narrowed to a single encounter

* '''A title''' — a short label for what the thread is about

* '''Messages''' — the entries posted into the thread over time by the care team

* '''A preserved history''' — authorship, timestamps, and prior versions of every edited message

A note is not a substitute for structured clinical data. Diagnoses belong in [[Concepts/Condition|conditions]], allergies in [[Concepts/Allergy & Intolerance|allergy records]], and measurements in [[Concepts/Observation|observations]]. Notes are the human layer that ties that data together — the reasoning, context, and discussion that coded fields can't hold.

== Threads and messages ==

Notes live in a two-level structure: '''threads''' that hold '''messages'''.

* A '''thread''' is one conversation, anchored to a patient and optionally to one of that patient's encounters.

* A '''message''' is a single entry inside a thread. Many people can add messages to the same thread over time.

That anchoring gives a thread its scope:

{| class="wikitable"

|-

! Scope

! What it means

! Typical use

|-

| Patient-level

| Attached to the patient, not to any one visit

| Longitudinal commentary across encounters — care coordination, ongoing concerns

|-

| Encounter-level

| Attached to a specific [[Concepts/Encounter

| encounter]]

|}

Because threads hang off the patient record, they follow the patient over time. Deleting a patient removes their threads; deleting a thread removes its messages.

== Edit history ==

A note is meant to be an auditable record, not just a scratchpad. When someone edits a message, the new text becomes the visible body — but the previous version is never thrown away:

<syntaxhighlight lang="text">Posted → Edited → Edited again</syntaxhighlight>

Each edit appends the prior text, its author, and the time of the change to the message's history, oldest first. The platform maintains this trail server-side; clients cannot rewrite or erase what was already said. So a thread reliably shows not only what the team currently thinks, but what was written and when.

== Permissions ==

Notes have no permission file of their own. Access follows the [[Concepts/Patient|patient]] and [[Concepts/Encounter|encounter]] permissions, since every thread is anchored to a patient and may be scoped to an encounter.

{| class="wikitable"

|-

! Permission

! Description

! System Roles

|-

| <code>can_write_patient</code>

| Create or update a patient-scoped thread or message (used when the note is not tied to an encounter)

| Staff, Doctor, Nurse, Administrator, Admin, Facility Admin

|-

| <code>can_write_encounter_clinical_data</code>

| Create or update an encounter-scoped thread or message (the encounter must not be closed)

| Admin, Doctor, Nurse, Facility Admin

|-

| <code>can_view_clinical_data</code>

| Read a patient's clinical record, including their note threads and messages

| Staff, Doctor, Nurse, Admin, Facility Admin

|-

| <code>can_read_encounter_clinical_data</code>

| Read encounter-scoped threads and messages when patient-level clinical access is not granted

| Admin, Doctor, Nurse, Facility Admin

|}

Roles are granted through a person's organization, facility, or patient membership, then cascade down the organization tree — access granted at a parent organization flows to the facilities and patients beneath it.

{{Related}}