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Clinical notes, signing and amendments

Four note formats, practice templates, the 48-hour edit window, and the signature that closes an entry for good — with the amendment as the only route to changing it.

Required permissions:
Practitioner
Reviewed: 2026-08-24

A clinical note is written in the active session and stays in the patient record for good. The Note format field gives you four options: SOAP, Free Text, Template and Visit Card.

A note has two time boundaries. The first is the edit window — 48 hours from creation, after which the entry becomes read-only. The second is the signature, which closes the entry immediately, regardless of those 48 hours.

Open note templates

How to do it

01

Choose the format

  • SOAP — four fields: Subjective (what the patient reports), Objective (examination findings), Assessment (clinical reasoning, diagnosis), Plan (what was done, the home program, the plan for the next visit).
  • Free Text — one field with the hint "Describe the course of the visit…".
  • Template — fields defined by the practice.
  • Visit Card — a structured examination, described in a separate article.

Changing the format mid-writing does not delete what is already saved — but the new format has different fields, so the earlier content stops being visible in the editor.

02

Write — saving happens by itself

Below the field you see Draft saved once the changes are stored. Coming back to an unfinished note you will see Draft restored. With no network Heltio shows No connection — your draft has been saved and sends the content on once the connection returns.

Leaving with unsaved changes brings up an Unsaved note dialog with the choice Keep editing or Leave (draft saved).

03

Use a template

Select a template opens a list split into System Templates and Custom Templates, with search and a Last used marker. Changing the template mid-writing is warned about: "Switching templates will clear your unsaved field values."

Custom templates are created under Settings → Note templates. A system template cannot be edited or turned off — to adapt one, use Duplicate. Deleting a template does not touch the notes that used it; they display with a note that the template has been deleted.

04

Attach files

You can attach at most 10 attachments to a single note, each up to 10 MB. Accepted formats: JPEG, PNG, HEIC, PDF, DOCX. Each file may have a Caption (optional).

05

Sign and lock

Save and sign the visit opens the confirmation Sign and lock this entry?: "The signature attests the content of the medical record. A signed entry cannot be edited — any change becomes a separate, linked amendment with a stated reason."

After you confirm, Heltio acknowledges with The entry has been signed and locked. The entry gets a Signed marker with a name and a date, and Version 1.

06

Correct a signed entry with an amendment

Add amendment creates a new revision holding the original content. In the Reason for amendment field you write what you are correcting — a minimum of 10 characters, because the reason is part of the medical record.

Once saved, the new revision gets an Amendment marker and the next revision number, and the old one shows This entry has been amended — a newer revision applies. with a Go to the current revision link. The original stays untouched — that is the whole point of an amendment.

When something goes wrong

NOTE_SIGNED_LOCKED
Warning

This entry is already signed.

What this means: A signed note is closed. Heltio refuses every change to its content — in the browser the fields are greyed out, and a change sent from the mobile app comes back rejected under this code.

What to do: Use **Add amendment**. A new revision is created with the reason given, and the signed original stays in the record unchanged.
EDIT_WINDOW_CLOSED
Warning

The 48-hour edit window has closed. This note is now read-only.

What this means: More than 48 hours have passed since the note was created.

What to do: You can no longer change the content. If the entry is signed, use an amendment. If it is not — add a new note to the same visit.
Warning

Please fill in at least one field

What this means: You are trying to save a note in which every field is empty.

What to do: Fill in any field. An empty note is not documentation.
Warning

File exceeds 10MB limit.

What this means: The attachment is larger than the permitted size for a single file.

What to do: Shrink the photo or split the document. The limit is 10 MB per file and 10 files per note.
Warning

You cannot countersign your own note

What this means: A countersignature is a second person's confirmation — you cannot give it to yourself.

What to do: A trainee's note is approved by a Coordinator, a Senior Physiotherapist, an Administrator or the Owner.
Info

No connection — your draft has been saved

What this means: The device lost its network while you were writing.

What to do: Keep writing. Heltio sends the content on once the connection returns. Do not close the browser tab until you see **Draft saved**.

Who has access

Practitioner

Notes are created and edited by the roles that document care: Practitioner, Coordinator, Senior Physiotherapist, Trainee, Occupational Therapist, Speech and Language Therapist, Psychologist, plus the Owner and the Administrator. Technician / Massage Therapist and read-only clinical access see the notes but do not write them.

Countersigning is a separate permission and only the Owner, the Administrator, a Coordinator and a Senior Physiotherapist have it. The Countersign queue in the side menu appears at hospital sites.

Every signature, every amendment and every note deletion leaves an entry in the audit log.

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