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Creating records during and after meeting with a client
Creating records during and after meeting with a client

Recommended practice for creating accurate client records

Rachel Henare avatar
Written by Rachel Henare
Updated over a year ago

At the core of Noted is a tailored solution for taking high-quality, structured client records. Our aim is to support service providers in the work they do by providing a system that is relevant and easy to use so that you can focus on supporting your clients.

The way we have designed the record creation process improves the quality and accuracy of the information that you are gathering. This is important not only for your clients’ records but also for keeping yourself safe as a professional practitioner.

One of the easiest ways to ensure you are capturing accurate client information is to record it during your discussion with the client.

For those used to writing notes out by hand, while this will be a familiar concept, we often find this practice gets lost in the transition to a digital system. Reasons for this include:

  • Typing may be slower than short-hand

  • Users cannot touch-type, but can quickly scrawl notes

  • Looking at a screen reduces focus and engagement with the client

  • Providing a physical therapy like massage or acupuncture doesn’t allow time for entering notes into a device

Noted is designed in such a way that it’s easy to quickly take high-quality notes during an appointment while maintaining engagement with your client. While the change to digital may take some getting used to, we recommend persevering with recording client notes during a session in order to capture the most accurate information possible.

Get familiar with form content

Knowing which form to use in a record and how these forms are structured will save you time. We recommend investing some time in looking at each of the forms available and exploring the various options in each form to ensure you are aware of any nested content.

If you feel the content in Noted is not wholly reflective of the work you do, learn about updating forms and templates here.

Discuss, listen, then write

A common misconception is that you should be writing down information as it is provided. We recommend that you take the time to focus on listening to your client, then when it is appropriate, start to reiterate to the client what was discussed, recording this in the relevant forms in Noted as you go. This shows the client that they are being listened to and care is being taken to support them. Entering information into a record in this way also provides a client with the chance to clarify details that you may have missed whilst also ensuring you’re following best practices.

Sign records on the day they are created

The best way to ensure the information you are recording is as accurate as possible is to record it while it is still fresh in your mind.

It may not always be possible to finish and sign a record during a client appointment. To help keep track of any records that are waiting to be completed, you will find a list of Unsigned records on your Dashboard.

We recommend that records are signed the day they were created. If you find you have signed a record before it was complete or if new information comes to light that should be included with a signed record, you can add an Addendum.

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