Concepts/Clinical Notes
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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 conditions, allergies in allergy records, and measurements in 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:
| 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:
Posted → Edited → Edited again
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 patient and encounter permissions, since every thread is anchored to a patient and may be scoped to an encounter.
| Permission | Description | System Roles |
|---|---|---|
can_write_patient
|
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 |
can_write_encounter_clinical_data
|
Create or update an encounter-scoped thread or message (the encounter must not be closed) | Admin, Doctor, Nurse, Facility Admin |
can_view_clinical_data
|
Read a patient's clinical record, including their note threads and messages | Staff, Doctor, Nurse, Admin, Facility Admin |
can_read_encounter_clinical_data
|
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
Pages that link here:
- Concept: Concepts/Observation
- Reference: References/Notes
Wiki: ohcnwiki.tellmey.fyi