Electronic signatures and correcting clinical notes

Clinical notes are signed electronically when the visit is closed. After that, changes are made through versioned corrections; the old note is never deleted.

Why

Medical records must be traceable: who wrote what, when, and what was changed. Deleting medical record content is not allowed.

Correcting a note

1. Open the visit from the patient's history.
2. Choose Correct on the note (permission "Make versioned corrections to clinical notes").
3. Change the content and enter the reason for the correction (required).
4. Save and sign. The new version becomes the active version; the previous version is kept and can still be viewed.

Notes

• Data already sent to SATUSEHAT (the national health data platform) is updated automatically when the related resource changes (for example, a diagnosis).
• Invoice or financial corrections are not made here; use void or return at the cashier.