Chart Notes

Overview

Chart notes are clinical documentation your team creates for a patient — visit summaries, assessments, plans, and other staff-facing records stored in the patient chart. From the chart, you can view existing notes or start a new one for that patient.

Chart notes are clinic-only documentation. They are never shared with the patient in the patient portal and are never shared with outside providers through Avara Connect.

Chart Notes Tab

Open a patient’s chart and go to the Chart Notes tab to see a chronological feed of documentation, newest to oldest. This gives providers and staff a single timeline of signed notes and in-progress work for that patient.

Creating Chart Notes

Start a new chart note from the patient chart when documenting an encounter or follow-up. Chart notes can be entered in two ways:

• Typed — Compose directly in the editor
• Dictated — Use speech-to-text dictation supported for chart notes, the same way you might dictate other clinical content in the platform

Progress automatically saves as you work. Notes remain drafts until signed — draft content is not treated as finalized clinical documentation and is not visible as a completed note until a provider signs it.

AutoChart

Visits can also be recorded and automatically turned into a chart note using AutoChart. AutoChart captures the encounter and generates documentation from the recording. You can initialize the note with your chart note templates so the generated content follows your preferred sections and structure.

After initialization, the result is a normal chart note draft — it follows the same auto-save, reassignment, signing, and edit-history rules as any other chart note you create manually.

Users with Can Use AutoChart permission can use this workflow. See Inviting Users for access requirements.

Linking Appointments

You can attach an appointment to a chart note so the documentation appears alongside that visit in the patient’s record. This ties clinical notes to the scheduled encounter they belong to and keeps the chart easier to navigate for staff.

Templates

Under Templates, any user can create custom chart note templates with built-in sections and macros for repeatable, detailed documentation. Templates help standardize structure across providers and/or visits while still allowing personalization per user.

The platform includes a drag-and-drop chart note template builder. Arrange sections and blocks in the order that fits your workflow, then reuse the template whenever you create a new note.

Templates are ideal for common visit types — annual exams, procedure notes, follow-ups — where consistent headings and macro text save time without sacrificing completeness.

Drafts, Signing, and Reassignment

Until a chart note is signed, it stays a draft:

• Drafts auto-save so work is not lost
• Drafts are not viewable as finalized notes until signed
• Drafts can be reassigned to another user — for example a scribe, resident, or MA completing documentation for the appropriate provider to review and sign

Signing locks the note as completed clinical documentation for that version of the record.

Editing Signed Notes

Signed chart notes can be edited after signing when corrections or addenda are needed. The platform keeps a full edit history readily available for auditing — every change is traceable so your organization maintains a clear documentation trail.

Privacy and Sharing

Chart notes are viewable to all authorized users within your organization. They are internal clinical documentation:

• Not visible to patients in the patient portal
• Not shared via Avara Connect with referring or partner providers

Patient-visible documents and appointment shares follow separate rules; chart notes remain staff-facing clinical documentation only. See Study Sharing for what is included when appointments are shared externally.