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Prerequisites: You should have at least one Note Template configured and Providers assigned before creating notes. Templates define the structure of your clinical notes.
Clinical notes in Decoda document patient encounters, treatments, and observations. Notes are built on structured templates with defined questions and answer fields, and can be created manually, generated by AI Scribe from audio recordings, or produced from uploaded documents. Every note is linked to a patient, a provider, and optionally an appointment. Notes keep your clinical documentation organized, searchable, and consistent across providers. With AI Scribe, providers can record an appointment and get a structured note generated automatically — no typing required.

AI Scribe Notes

Record an appointment and let AI generate a structured clinical note.

Manual Notes

Write a note by hand using a structured template.

Document Uploads

Upload images or PDFs and optionally extract note content with AI.

Attachments & Gallery

View and annotate all medical attachments across patients.

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Notes List

The Notes page displays all clinical notes in your organization, grouped into Notes Taken Today and Earlier Notes. Each row shows the patient name, a preview of the note content, contributing providers, the template used, visit date, and last edited date. Notes that have been signed off display a green checkmark. Pinned notes appear at the top of the list.

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Filter and Search Notes

Use the filter bar above the notes table to narrow results:
  • Note ID: Search for a specific note by its ID.
  • Patient Name: Filter by the patient’s name.
  • Patient ID: Search by patient ID.
  • Provider: Select one or more providers to see only their notes.
  • Locations: Filter by clinic location (visible when the Locations module is enabled).
  • Template: Select one or more templates to see only notes created with those templates.
  • Created Date: Filter by the date the note was created.
By default, the list is filtered to the current provider and primary location. Click Clear Filters to reset.

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Note Actions

Click the actions menu (three-dot icon) on any note row to access:
  • Edit — Open the note in the playground editor.
  • View — Preview the note in a read-only view.
  • Print — Print the note or export it to PDF.
  • Duplicate — Create a copy of the note with the same template and answers.
  • Pin / Unpin Note — Pin a note so it appears at the top of lists. Pinned notes are visible in the patient chart as well.
  • View Appointment — Navigate to the linked appointment on the calendar (only shown if the note is linked to an appointment).
  • Resume — For AI notes that were started but not yet generated, resume the recording session.
  • Delete — Permanently delete the note. Requires the Archive Notes permission.

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Create a New Note

Click the New Note button at the top of the Notes page. If a patient is already selected (for example, from within a patient chart), a dropdown appears offering AI Note or Manual Note. Otherwise, a window opens where you choose:
  1. Patient — Search and select the patient.
  2. Note Type — AI Note, Manual Note, or Upload.
  3. Template — For manual notes, select a template before creation. For AI notes, the template is selected during or after recording.

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Quick Notes

Quick notes are short, freeform text notes that can be attached to an appointment from the calendar. Unlike clinical notes, quick notes do not use templates or structured fields. They are designed for brief observations or reminders (for example, “Patient arrived 10 minutes late” or “Rescheduled from last week”). Quick notes are created and edited from the appointment detail panel on the calendar.

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Advanced Configuration

Templates are created and managed under Settings > Note Templates. From there you can:
  • Create new templates with structured questions (text, multi-select, toggles, file uploads, scribe attachments).
  • Set provider access controls to restrict which providers can use each template.
  • Configure note expiry periods.
  • Manage image tags for categorizing attachment photos.
  • Duplicate or delete templates.
  • Bulk delete multiple templates at once.
See Note Templates Settings for full details.
The AI Scribe assistant can be customized under Settings > Assistants > Scribe:
  • Assistant Name — Set a display name for the scribe assistant.
  • Custom Prompt — Provide specific instructions that guide how the AI generates notes from transcripts. Use dynamic variables (patient info, tenant details) for personalized output.
  • AI Model — Select which AI model powers the scribe (for example, different models may offer varying speed/quality tradeoffs).
See Assistants Settings for details.
Each provider can toggle automatic note sign-off in Settings > Preferences. When enabled, notes created by that provider are automatically signed off upon saving, eliminating the need for a separate sign-off step. This is useful for solo practitioners who review notes as they write them.
Image tags help categorize attachment photos across notes. Tags are managed under Settings > Note Templates in the Image Tags section at the bottom of the page. Each tag has a name and color. Tags can be applied to individual attachments within a note for better organization and searchability.
Several permissions control access to note features:
  • AI Scribe Use — Required to create AI notes and access recording features. Without this permission, only manual notes are available.
  • Sign Off Notes — Required to sign off on notes. Providers without this permission cannot finalize notes.
  • Archive Notes — Required to delete notes from the notes list.
Permissions are configured under Settings > Users & Roles.