Clinical notes, signing & addenda

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Clinical work belongs to the patient's care episode. Open the episode from the patient or choose SOAP note on the whiteboard. Check the patient, practice and visit before entering clinical information.

Understand the episode

An appointment reserves time; checking in opens the episode used for the visit. The episode holds its clinical documentation and connects it with the surrounding work. Existing episodes remain part of the patient's practice history, so choose the current visit rather than reusing an older record to avoid creating another entry.

Where the owner has granted access, connected health information can add context to the visit. Read source dates and sharing scope before treating it as a complete history. See patient history.

Write and review the SOAP note

With clinical notes enabled, an approved veterinary account with the appropriate practice role can write the SOAP note. Work through Subjective, Objective, Assessment and Plan, separating reported history from findings and clinical decisions.

Drafts autosave. Check the saved state before leaving or switching to another patient, especially after a connection problem. If saving has failed, preserve the text you need and resolve the error before assuming the team can see the latest version.

Petus Scribe can help prepare a draft from a transcript. Review any transferred text against the patient and the visit. Marking a Scribe note reviewed does not sign it or automatically add it to an episode.

Sign the record

Review each section, patient identity and any related clinical details before choosing Sign note. Signing creates a permanent record of that version. Practice membership does not let a colleague sign as you.

An incomplete draft should remain a draft until the responsible clinician has reviewed it. Moving the visit on the whiteboard or recording a payment does not replace clinical signing.

Add a correction after signing

Use an addendum for a correction or later information about your signed note. The original signed content remains preserved. Make the reason and new information clear so someone reading the history can understand what changed and when.

Follow the available record controls for flags, related documents and exports. A signed record has its own custody rules; it is distinct from ongoing permission to read an owner's shared Petus history. Read data access and custody for that distinction.

Keep the next action visible

Use Follow-ups for a task with an assignee, priority and due date. Use the Lab inbox for staff-entered results awaiting veterinary review. These queues keep work visible after the current visit ends.

Client communication belongs in the Inbox. A note describing a plan does not itself send that plan to the owner.

If a note or action is unavailable, check the selected practice, role, professional approval and current record access. Ask your practice admin about membership and Petus support about a pending professional application.