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Create a Manual Note

Manual notes are written by hand using a structured template. Each template defines the fields (questions) to fill in.
1

Start a New Manual Note

Click New Note and select Manual Note. If you are inside a patient chart, the patient is pre-selected. Otherwise, search for and select the patient.
2

Select a Template

Choose a note template. A template is required for manual notes — you cannot proceed without selecting one.When a template is selected for a patient, some fields may auto-fill based on existing patient data (such as allergies, medications, or other previously recorded information). If auto-fill data is not available, fields will use default values.
3

Fill In the Note

The note editor shows the Doctor’s Note tab with each question from the template. Depending on the question type, you may enter:
  • Free text or long text — Type directly in the field.
  • Single select / Radio — Choose one option.
  • Multi-select / Checkboxes — Choose one or more options.
  • Yes/No — Switch on or off.
  • Number — Enter a numeric value.
  • Measurement fields — Enter values configured in Settings > Measurements.
  • Date — Pick a date.
  • File upload — Attach a file directly within the question.
  • Attachments (Scribe Attachments) — Photos with annotation support.
4

Save

Click Save to persist the note. Unsaved changes are tracked — the Save button is only enabled when edits have been made.
After the note has answers, an AI chat box appears at the bottom of the Doctor’s Note tab so you can ask AI to clean up or expand the note. See Ask AI to Refine the Note for how it works. While you move between note views, Decoda keeps your unsaved note edits, selected medical codes, and typed Ask AI message available on that note. Saving the note clears those saved drafts.

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Change a Template on a Manual Note

If a manual note was created without a template, a template selection window automatically appears. You can also switch templates by selecting a new one, which replaces the current note structure. Any unsaved edits will be lost.

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Note Templates

Templates define the structure of your clinical notes. When creating or editing a note, you select a template that determines which questions and fields appear.

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Select a Template

The template selection window shows all templates you have access to. Key features:
  • Search — Type to filter templates by name or question content.
  • Favorites — Click the star icon next to a template to mark it as a favorite. Favorited templates appear in a dedicated section at the top of the list for quick access.
  • Question count and attachment count — Each template row shows the number of questions and any placeholder attachments.
  • Access restrictions — Templates may be restricted to specific providers. If you do not have access to a template, it appears greyed out.
  • Create New Template — Click the link at the bottom to open the template editor in a new window.
To create and manage note templates (add questions, set access controls, configure expiry), go to Settings > Note Templates. See Note Templates Settings for details.

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Medical Codes

When the Medical Codes module is enabled, notes include a Codes tab where you can:
  • Search and attach ICD-10 diagnosis codes.
  • Search and attach CPT procedure codes.
  • Save code selections alongside the note.
This tab only appears for notes that have generated content and when the SCRIBE_MEDICAL_CODES module is active for your organization.

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Medication Doses

The Medical Notes tab within a patient chart includes a Medication Doses section that tracks all doses and injections administered to the patient. This table shows:
  • Medication name and details.
  • Dose amount, units, and lot number.
  • Administration date and provider.
  • Sign-off status — Doses can be signed off individually by authorized providers. Signed-off doses show the provider who signed them and the date when that information is available.
Use the Add Dose button (when available) to record a new medication administration. Each dose can be linked to a specific note. To update an existing dose from the note or patient chart, open the dose’s actions menu and select Edit Dose.

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Measurements and Charts

The patient’s Medical Notes & Data tab includes a Measurements section for tracking vitals and custom measurement fields. Click Add to record a group or individual field. If the note template includes Measurements or Measurement Groups, values entered in the note are saved to the patient’s Measurements section when you click Save. For weight-loss clinics, additional charts, such as dose tracking and waist circumference, appear within the note editor for enrolled patients.