Clinical records, SOAP visit notes and signed records
A visit note follows the physician's order of thought: complaint, findings, assessment and plan. It is saved as a draft while you write, and after the physician reviews and signs it the record is locked. Every addition and correction made after signing appears with who made it, when and why.
The record speeds up the physician's work and protects what is written
A clinical record has to do two things at once: save the physician time during the visit and make sure what was written cannot change later. Fast systems make corrections easy but can erase the trace, and strict systems slow the physician down.
HekimBis keeps the draft stage fast and the signed stage fixed. In a draft you write and correct freely, the record saves itself, and even if you close the page you continue where you left off. The moment you sign, the record is locked.
The structure of a visit adapts to the specialty. SOAP, quick notes and specialty-specific structured visit types run on the same record engine, and a specialty pack adds its screen sections, scales and ready-made texts.
The parts of a visit follow the physician's order of thought
Every visit follows the same skeleton, and a specialty pack adapts the order of the sections, the scales and the ready-made texts. Information entered in one section is not retyped in later sections or on other screens of the patient file.
- History
- Complaint, personal and family history, allergies, chronic conditions, active medication and risk flags are collected together. Allergies and risk flags show on the patient card as alerts, so the physician does not hunt for them each time.
- Vital signs
- Vital signs are recorded as measurements and followed as trends over time. With a connected device the reading arrives through the device connection; without one it is entered by hand.
- Physical examination and findings
- The physical examination and structured findings are filled in according to the specialty's schema. Because findings are kept in fields rather than free text, they can be compared and reported later.
- Diagnosis and procedure
- The diagnosis, procedure and clinical assessment are linked. A procedure connects to its stock kit, the treatment plan and, where needed, the price and accrual, so the same information is not typed twice after the visit.
- Plan and follow-up
- The problem list, care plan, goals, follow-up and referral sit in this part. A need for a check-up becomes a recall task, and the clinical summary, referral letter and patient file printout are generated from the record.
- Medication and prescription
- The physician prepares a medication and prescription draft, approves it and prints it. Because the active medication and allergy list are visible during the visit, the draft is considered alongside the patient's current treatment.
From draft to signed record, then addendum and correction
Every visit record follows the same path. The draft saves itself, the physician reviews and signs, and the record is locked. If information has to be added later an addendum is opened, and a mistake is corrected with a reason and a trace. A signed record cannot be edited directly.
Correction (with reason, traced)
If there is an error, the correction record is kept with its reason and the previous version alongside.
- The process is complete here.
- Day 1 · 10:05SignedPhysician A
- Day 2AddendumPhysician A · new information
- Day 3CorrectionReason: wrong field
The names, times and records on the screen are examples.
All steps
- 01 Draft (Physician) The physician opens the examination record and begins writing. The record is a draft and freely editable.
- 02 Autosave (System) The system saves what is written automatically; the draft is kept even if the page is closed.
- 03 Physician review (Physician) The physician reviews the record: missing fields, inconsistencies, correct patient and date. If satisfied they go to signature; otherwise back to the draft.
- 04 Signature and lock (Physician) The physician signs; the record locks and is pinned to the form and specialty-pack version.
- 05 Addendum (Physician) If information needs to be added later, an addendum is opened without touching the signed record, with who and when.
- 06 Correction (with reason, traced) (Physician) If there is an error, the correction record is kept with its reason and the previous version alongside.
Alternative path from 03 Physician review; it returns to the main flow at 01 Draft.
- 03a Review: correction needed (Physician) The physician sees a missing or wrong field; the record stays open as a draft, is corrected and returns to review.
Alternative path from 04 Signature and lock; it returns to the main flow at 06 Correction (with reason, traced).
- 04a Attempt to edit a signed record (System) Someone tries to change the locked record directly. The system rejects it; a correction record with a stated reason is opened instead.
06 Correction (with reason, traced)
Visits are linked within an episode
Visits that belong to the same health problem are gathered under an episode, so the physician follows the patient's course without opening each record separately.
- Episode and course of treatment
- From start to closure, a course of treatment shows together with its visits and its plan.
- Visit comparison
- Two visits open side by side, and the difference in findings, measurements and assessment is visible.
- Measurement and result trends
- Vital signs and test results are followed as trends over time, and a comparison warning appears when the unit or method has changed.
- Problem list and care plan
- Chronic conditions stay on the problem list, and the care plan is updated together with its goals, follow-up and referrals.
Access to the clinical record is decided by role, branch membership, the care relationship and the sensitivity of the note. Sensitive notes can be segmented with a narrower scope and masked at field level, and every read and change is written to the audit trail.
A signed record never changes silently
After signing, the record is locked. If something is to be added, an addendum is opened, and if something is wrong the correction is stored with its reason next to the original. For every change, who, what, when and why stay on the record.
This is how physicians and the organization protect the integrity of their records, and it lets you show when and how a record came about in a data request or a dispute. A record stays tied to the form and specialty pack version it was created with, so an update to the pack never changes the meaning of an older record.
An addendum or correction sits beside the signed record as a separate version. When the physician opens the patient file the latest state is shown first, and earlier versions are one step away. In a data request or a dispute, when, by whom and for what reason the record changed can be shown item by item.
Frequently asked questions
How does a specialty pack change the visit screen?
A pack brings the menu, section order, scales and ready-made texts of the specialty. Because the record engine stays the same, the physician keeps working in the same patient file.
Can I use a visit format other than SOAP?
Yes. SOAP, quick notes and specialty-specific structured visit types are available. A specialty pack adds its own section order, scales and ready-made texts, and your clinic can define local sections and templates too.
Could I lose what I have written?
The draft is saved automatically while you write, and even if you close the page it is kept and you carry on where you stopped. Until it is signed, the physician can edit the record freely.
What if I need to correct a signed record?
A correction entry is opened with a reason, and the earlier version is kept as well. A new piece of information is added through an addendum. In both cases who changed it, when and why stay on the record.
Can I write prescriptions?
You can prepare a physician-approved medication and prescription draft and print it. The active medication and allergy list stays on screen while you prepare the draft.
Which documents are generated from a visit record?
The clinical summary, referral letter and patient file printout are generated from the record. Ready-made texts, order sets, protocols and document templates come with the specialty.
Who can access the records?
Access depends on role, branch membership, the care relationship with the patient and the sensitivity of the note. Sensitive notes can be protected with a narrower scope, and every read and change is written to the audit trail. See the roles and permissions page for details.
How do diagnosis and procedure codes relate to national data reporting?
The signed clinical record is the source of national data reporting. The relevant clinical event is turned into a data package with versioned mapping rules, and the source record never changes silently. See the e-Nabız and USS reporting page for details.
How do physician review and signing work?
When the draft is ready, the physician reviews and signs it, and the record is locked at the moment of signing. Until then the physician can edit it freely.
Where do specialty-specific visit sections come from?
Sections, scales and ready-made texts come from the specialty pack and run on the same record engine. A physician can work with several packs, and the patient remains one record.
How are referrals and follow-up managed?
The plan section holds the problem list, care plan, goals, follow-up and referral details. A need for a check-up becomes a recall task, and the referral letter and clinical summary are generated from the record.
Can I compare against earlier visits?
Yes. Episodes and the course of treatment, visit comparisons, and measurement and result trends are followed in the patient file.
Keep reading
Related pages
Features
Specialties
- Internal medicineSystems-based exams, lab trends, and chronic disease care plans.
- NeurologySeizure and attack diaries, neurological exams, EEG/EMG results, medications.
- General surgeryPre-op assessment, surgical planning, consent, and wound follow-up.
- General practiceFast visit notes, vital sign trends, and recall plans for general practice.
Software guides
Guides
- Digital Clinic Management Guide for Moving from Paper to an Orderly FlowGoing digital in a clinic is not buying software; it is rebuilding the workflow. The flow from appointment to payment, and the steps that get skipped during the move.
- e-Prescription in the Clinic and Where the Prescription Draft Sits in the Examination RecordWhat is e-Prescription, where does it sit in a physician's workflow, and what does clinic software do? How a prescription draft is prepared, approved and stored with the examination record.