Finalising notes
Approving a note is the moment a draft becomes the finalised clinical record. It’s a deliberate, clinician-only step.
Approval is your clinical sign-off. By approving, you’re confirming the note is accurate, complete, and appropriate. Never approve a note you haven’t fully read and verified.
Before you approve
Work through the review checklist first. At minimum, confirm:
- The correct patient.
- Accurate history, findings, assessment, and plan.
- Correct medications, referrals, and follow-ups.
- Safety-netting advice where appropriate.
Full checklist: Review & approve notes.
Steps
Final read
Read the note one last time, top to bottom.
Approve
Use the approval control to finalise the note.
Confirm downstream actions
After approval, close the loop — referrals, follow-up tasks, recalls, and patient communication. See After a consultation.
What happens after approval
- The note becomes the finalised record for that consultation.
- The approval is recorded in the audit trail. See Audit trail.
- You may be able to export the note (for example, as a PDF) where your clinic uses that. Needs confirmation — confirm the export options available in your version.
Correcting a finalised note
If you find an error after approval, correct it through your clinic’s process for amending records rather than pretending the original never happened. Amendments are tracked. Needs confirmation — confirm your clinic’s amendment workflow.
Safety notes
Approval and any later amendments are auditable events. This protects both the patient and you by keeping an accurate history of who did what, and when.
Common mistakes
- Approving to “get it off the list” without a final read.
- Forgetting to close the loop on referrals and follow-ups after approving.
Troubleshooting
- Approval control missing or greyed out? Check your role and access level. See User roles & access.