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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.
  • Toggle — Switch on or off.
  • Number — Enter a numeric value.
  • 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.

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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.
Use the Add Dose button (when available) to record a new medication administration. Each dose can be linked to a specific note.

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Measurements and Charts

The patient’s Medical Notes tab also includes a Measurements section for tracking vitals:
  • Add Measurements — Click to record weight, height, blood pressure, waist circumference, and other vitals.
  • Weight Chart — Automatically displayed when two or more weight measurements exist, showing trends over time.
  • Blood Pressure Chart — Automatically displayed when two or more blood pressure readings exist.
For weight-loss clinics, additional charts (dose tracking, waist circumference) appear within the note editor for enrolled patients.