Write Visit Notes

Visit notes capture what happened during a patient encounter: the reason for the visit, findings, assessment, and plan.

DPC Pro provides a structured note-writing environment designed for the way DPC clinicians work. Notes are tied to scheduled visits and become part of the patient’s permanent clinical record. You can write notes during or after a visit, using templates that match common encounter types.

This page covers how to create a visit note, use note templates, and finalize documentation. Visit notes are visible to all clinicians in your practice who have access to the patient’s record, supporting continuity of care across providers.

Thorough visit documentation protects your patients, supports clinical decision-making, and satisfies medical-legal requirements.

Start a Visit Note

There are three ways to start a new visit note, depending on where you are in DPC Pro.

From the Schedule

If the patient has a scheduled visit, you can create a note directly from the visit:

1. Navigate to Schedule.
2. Open the visit you want to document.
3. Select New Clinical Note from the visit detail.

The note is automatically linked to that visit. The visit date, chief complaint, and note type are pre-filled based on the scheduled visit details. For example, a telehealth visit pre-selects the Telehealth Note type, and a phone visit pre-selects Phone Note.

From the Patient Record

1. Navigate to Patients and open the patient’s record.
2. Select New Clinical Note from the patient’s actions panel.

The patient is pre-selected, and you proceed to filling in the note details.

From the Clinical Notes List

1. Navigate to Clinical Notes.
2. Select New Note in the upper-right corner.
3. Search for the patient by name or MRN in the search field.
4. Select the correct patient from the results.

Linked Visits

When you start a note from a scheduled visit, the note and visit are linked. This connection appears on both the note detail and the visit detail, so any clinician can navigate between them.

Note Editor Layout

The note editor uses a three-panel layout:

• Left sidebar: patient context panel showing allergies, current medications, chronic conditions, surgical history, and primary provider. On mobile, this panel is accessible through a menu button.
• Center: the SOAP editor where you write the note content.
• Right sidebar: quick actions including linked visit details, upcoming visits, previous notes for this patient, and active prescriptions. This panel appears on larger screens.

The patient’s name, age, and MRN appear in the editor header, along with the note type selector, visit date, and a status badge showing whether the note is a Draft, In Progress, Completed, or Signed.

Note Templates

When creating a note, select a note type from the dropdown in the editor header. Each type provides a structured template suited to different encounter types:

Note Type	Best Used For
SOAP Note	Standard in-person visits with subjective, objective, assessment, and plan sections
Progress Note	Follow-up visits for ongoing conditions
Phone Note	Documenting phone consultations
Telehealth Note	Virtual video visits
Procedure Note	Documenting procedures performed during a visit
Consultation Note	Specialist consultations or second opinions

All note types use the SOAP structure (Subjective, Objective, Assessment, Plan). The note type label helps categorize notes in the clinical notes list and allows filtering by type later.

Default Type

SOAP Note is the default type for new notes. When you create a note from a scheduled visit, the type is suggested based on the visit type (for example, telehealth visits suggest Telehealth Note).

Editing and Formatting

Writing SOAP Sections

The note editor presents four sections, each in its own card:

1. Subjective (S): document the patient’s symptoms, history, and chief complaint in their own words. The placeholder text reads: “Patient’s symptoms, history, and chief complaint in their own words…”
2. Objective (O): record physical exam findings, vital signs, lab results, and imaging. This section includes a vitals entry area and a free-text field.
3. Assessment (A): enter your diagnosis, differential diagnosis, and clinical impression. This section includes a diagnosis code search for attaching ICD-10 codes.
4. Plan (P): describe the treatment plan, medications, referrals, and follow-up instructions.

Each section uses an auto-growing text area. The field expands as you type so you do not need to scroll within a single section. If your practice has the AI assistant enabled, you may see AI-generated suggestions to help complete sections based on prior visit context.

Chief Complaint

Enter the chief complaint in the field at the top of the editor, below the patient header. This field accepts up to 500 characters and appears on the notes list and note detail pages.

Recording Vitals

To record vitals for a visit:

1. In the Objective section, select Edit Vitals.
2. Enter values in the vitals modal. Available fields:
   • Temperature (in Fahrenheit)
   • Blood Pressure (systolic / diastolic)
   • Pulse (beats per minute)
   • Respiratory Rate (breaths per minute)
   • SpO2 (oxygen saturation percentage)
   • Weight (in kilograms)
   • Height (in centimeters)
3. Save the vitals. They appear as a summary grid above the Objective text area.

All vitals fields are optional. Record only the values relevant to the visit. Vitals are available after the note has been saved at least once.

Adding Diagnosis Codes

To attach ICD-10 diagnosis codes to a note:

1. In the Assessment section, select Add ICD-10 Code.
2. In the search modal, type at least two characters of a code or description.
3. Select a code from the search results. Up to 20 matching codes are shown.
4. The code appears as a tag in the Assessment section.

To remove a code, select the remove button on the code tag.

Diagnosis codes are available after the note has been saved at least once.

Search by Code or Description

The ICD-10 search matches against both the code itself (for example, typing J06 finds upper respiratory infection codes) and the description text (for example, typing hypertension finds all related codes).

Auto-Save

DPC Pro automatically saves your work every two minutes while editing. The save indicator in the editor header shows the current state:

• Saved: all changes have been saved
• Unsaved changes: edits exist that have not been saved yet
• Saving…: an auto-save is in progress
• Save failed: the auto-save encountered an error; try saving manually

You can also save manually at any time by pressing Ctrl+S (or Cmd+S on Mac). When you first start writing in a draft note, the status changes from Draft to In Progress.

Distraction-Free Mode

For focused writing, toggle distraction-free mode by selecting the expand icon in the editor header or pressing Ctrl+Shift+F (or Cmd+Shift+F on Mac). This mode hides the side panels and centers the SOAP editor in a narrower column. Toggle again to return to the standard layout.

Unsaved Changes Warning

If you navigate away from the editor with unsaved changes, a browser prompt asks you to confirm. This prevents accidental loss of work.

Sign and Finalize a Note

Visit notes follow a defined workflow from creation to final signature:

Note Statuses

Status	Meaning
Draft	Note has been created but not yet written
In Progress	Writing has begun (set automatically on first edit)
Completed	Clinician has marked the note as complete and ready for review
Signed	Note has been signed and is now a permanent part of the medical record

Completing a Note

When you are finished writing and have reviewed the note content:

1. Select Mark Complete in the editor footer.
2. The note status changes to Completed.

Completing a note signals that it is ready for signing. You can still edit a completed note if you need to make changes before signing.

Signing a Note

Signing a note locks it as a permanent part of the patient’s medical record:

1. From a completed note, select Sign Note in the editor footer.
2. Review the note summary showing the patient name, visit date, note type, and author.
3. Check the confirmation box: “I have reviewed this clinical note and confirm that it is complete and accurate.”
4. Select Sign Note.

The note is now signed and displays the signer’s name and the date and time of signing.

Signing Is Permanent

Once signed, a note cannot be edited. Any corrections must be made through an amendment. Review the note carefully before signing.

Deleting a Draft

Only draft notes can be deleted. From the editor footer, select Delete Draft and confirm the deletion. Notes that are in progress, completed, or signed cannot be deleted.

Note History and Amendments

Viewing Note History

To view all notes for a patient:

1. Navigate to Clinical Notes.
2. Use the Patient filter or search by patient name to see notes for a specific patient.

Alternatively, from a patient’s record, select View Clinical Notes in the actions panel to see all notes filtered to that patient.

The notes list shows the patient name, note type, visit date, chief complaint, author, and status. Use the filters to narrow results by status, note type, or date range.

Creating an Amendment

If a signed note requires a correction or addition, create an amendment rather than editing the original:

1. Open the signed note.
2. Select Create Amendment.
3. Enter a reason for the amendment: this field is required and explains why the change is being made.
4. The amendment editor opens with the original note’s content pre-filled in all four SOAP sections. Edit the sections that need correction.
5. Select Create Amendment.

The amendment is created as a new note linked to the original. It starts as a draft, and you can continue editing it, add updated vitals and diagnosis codes, and then sign it through the standard workflow.

How Amendments Appear

• The original note displays a banner indicating it has been amended, with a link to the amendment.
• The amendment displays a banner identifying it as an amendment, with the reason and a link to the original note.
• Both the original and all amendments remain in the patient’s record. No content is overwritten or deleted.

Amendment Audit Trail

Amendments create a clear audit trail. The original note is preserved exactly as it was signed, and each amendment records who made the change, when, and why.

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Related Pages

• Problem Lists and Medications
• Patient Timeline and History
• Print and Share Records
• Schedule a Visit
• Patient Records

Need Help?

If you run into issues with visit notes, reach out to the DPC Pro support team at [email protected] or visit the troubleshooting guide.