Clinical notes and vital signs are the running record of what happened at each encounter — what the patient reported, what you observed, what you concluded, and what you plan to do next. Clinicians write them during or just after a visit, and the treating team reads them to stay aligned on a patient's care. Both live in the patient's clinical workspace — open a patient from Clinic → Patients, then use the Notes and Vitals tabs.
Clinical notes
The Notes tab lists every note by encounter date, with its status (draft, signed, or amended), visibility (for example treating team), and author. Click View to open one, or New note to write another.
The SOAP structure
A note follows the familiar SOAP structure — four sections that move from the patient's story to your plan:
- S — Subjective: what the patient reports (chief complaint, history of present illness, symptoms).
- O — Objective: what you measure and observe (vital signs, physical-exam findings, lab results).
- A — Assessment: your clinical impression (working diagnosis, differential diagnoses).
- P — Plan: what happens next (medications, procedures, follow-up, referrals).
Every section is optional, so a quick nursing note and a full consultation use the same form. You also choose who can see the note before saving.
From draft to signed
A new note starts as a draft, which stays fully editable — while you're on the edit screen it even autosaves every 30 seconds, so work in progress isn't lost. When the note is complete, Sign note seals it into the record and stamps the signing time. Signing is deliberate: a signed note becomes a permanent part of the medical record, so Nkapio locks it against further edits to preserve an accurate account of what was known and decided at that moment.
Correcting a signed note with addenda
Because a signed note can't be edited, later corrections or new information are added as addenda — short, dated entries that appear beneath the original. Adding the first addendum moves the note's status to amended. Addenda are append-only: they can't themselves be edited or deleted, so the trail of who changed what, and when, always stays intact.
Who can see a note
Visibility is set on each note:
- Treating team / All clinicians — any colleague with access to the patient's clinical records can read the note.
- Author only — the note is restricted to you and staff who have been granted confidential-record access.
Use Author only for sensitive entries; the default, Treating team, keeps care coordinated across the people looking after the patient.
Vital signs
The Vitals tab keeps a dated table of readings, newest first — blood pressure, pulse, temperature, SpO₂, respiratory rate, weight, height, and the BMI computed from them. Use Record vitals to add a new set at any visit.
Every field is optional, so record whatever the visit calls for. BMI is calculated automatically from weight and height (weight in kilograms divided by height in metres squared) and shown rounded to one decimal — it appears only once both weight and height are present. You can also capture a pain score (0–10) and a free-text note with each reading. Every reading is stamped with the time it was saved, and the latest value for each metric is surfaced on the patient's record for an at-a-glance snapshot.
Tips
- Use the Objective section of a note to summarise the vitals and exam findings behind your assessment.
- Need a hard copy? Open a signed note and use Print — the layout collapses to a clean A4 sheet.
- Notes and vitals need the clinical module enabled and the matching permissions; confidential (author-only) notes require the extra confidential-record permission.