Lock, Sign, and Timestamp Chart Notes (Addendums)
Lock or sign a chart note to prevent further edits and add a timestamp, with any post-lock updates captured through an addendum instead of directly editing the note. Only users with the correct permission can unlock a locked note, and doing so requires a documented reason. Addendums display in chronological order and can be added by other care team members or reviewing providers with the right permissions.
Built by Core Engineering
The problem it solves
Clinical documentation needs a point where a note becomes final for compliance and legal purposes, but providers still occasionally need to correct or add information after that point. This feature solves that by letting a note lock permanently against direct edits, while still allowing later additions through a transparent, timestamped addendum trail instead of silent edits to the original record.
What's included
- Sign Note and Lock Note options that timestamp a chart note and block further edits
- Chart Note Addendum for logging updates after a note is signed or locked
- "Can Unlock Chart Notes" permission, off by default for non-owners and requiring a documented reason to use
- Multi-provider signing support, with each signature and its timestamp recorded in Chart Note History
- "Can write addendums to charting notes of other providers" permission for cross-provider review workflows
How it works
While editing a chart note, a provider uses the drop-down next to Save to choose Sign Note, Lock Note, or Sign & Lock; any required template fields must be completed first. Once locked, the note cannot be edited except through an addendum, and the lock event, along with the provider and timestamp, is recorded in Chart Note History. To make a substantive change, a user with the "Can Unlock Chart Notes" permission (on by default for organization owners only) selects Unlock Note, acknowledges a Notice of Data Integrity, and provides a reason for unlocking before re-locking the note; this event is also recorded in the chart history. Any provider on the client's Care Team, or with an added "Can write addendums to charting notes of other providers" permission, can add an addendum to a signed or locked note, which displays in chronological order alongside other chart history events.
Lock, Sign, and Timestamp Chart Notes lets providers finalize a chart note by signing or locking it, which timestamps the note and blocks further edits to its original content. It's built for practices that need to preserve the integrity of clinical documentation once it's finalized, while still allowing necessary updates to be logged transparently. After a note is locked, any additional information must be added as a separate addendum rather than edited into the original note; addendums display in chronological order and can be added by other care team members with the right permissions. Unlocking a locked note requires the "Can Unlock Chart Notes" permission, which is on by default only for organization owners, and requires the user to document a reason before making changes.