Clinical Documentation & EMR
Keep the consultation and the patient record together
NextHealth Care
NextHealth Care
Included in all three Care plans.
NXH Care clinical documentation brings the consultation record into one workspace. Clinicians review vitals, allergies and history beside structured note fields, note templates and ICD-10 and CPT lookup. Where the facility has deployed the dictation service, speech is transcribed on the customer’s own infrastructure and the text is inserted into the note for the clinician to check. The treating doctor signs the note, which freezes it, and later changes are recorded as signed addenda with a reason.
Keep the consultation and its record together
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Step 1
Review context
Open vitals, allergies and history
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Step 2
Document
Write the note, with templates and dictation
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Step 3
Sign
The treating doctor signs and the note is frozen
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Step 4
Amend
Add a signed addendum with a reason
What your team can do
- Review vitals, allergies and history beside the note.
- Record the consultation in structured fields, with templates and shortcuts.
- Find ICD-10 and CPT codes by name or number.
- Dictate into a note field where the facility has deployed the transcription service.
- Sign the note as the treating doctor, which freezes what was signed.
- Amend a signed note with a signed addendum that records the reason.
Follow the note from draft to signature
A note that others rely on needs a clear history: who wrote it, when it was signed and what changed afterwards. In NXH Care the note is saved as a draft while the doctor works. Only the authoring doctor, holding the signing permission, can sign it. Signing freezes the note as the doctor saw it, with a signature hash, and finishes the encounter. A signed note is never edited. A correction is a new addendum, signed at once, linked to the original and carrying the reason for the change. Signing also opens the draft bill in Billing.
Dictation
Dictation is optional. Care sends the recorded clip to a transcription service designed to run on infrastructure the customer controls, so audio is not sent to a third-party speech provider. The service has to be deployed and connected for your tenant before dictation works. The transcript is added to the note field as text for the clinician to read and correct, and Care does not store the audio clip.
Clinical responsibility
Care records what the clinician enters. Coding lookup helps find ICD-10 and CPT entries, and the clinician chooses what is recorded. Dictation produces text, not a diagnosis, and Care does not make treatment decisions. The doctor remains responsible for the content of the signed note.
Illustrative example: a consultation note from draft to addendum
This example uses synthetic data.
Dr Karim Example opens a consultation for a synthetic patient, Lena Sample, and reviews her recorded allergies and latest vitals. He writes the subjective, objective, assessment and plan sections, which autosave as a draft, and looks up an ICD-10 code by name. When he signs, the note is frozen and the encounter finishes. Later he finds that he left out a detail. He cannot edit the signed note, so he adds an addendum with the reason and signs it. Both notes stay on the record, linked. Only the doctor who authored a note can sign it.
Related NXH Care modules
3 more modules
Common questions
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Clinical documentation is included in Care Clinics, Care Clinics Pro and Care Hospitals. The module is part of the shared clinical foundation in every Care plan.
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No. Care provides clinical coding lookup by name or number. The clinician selects the appropriate entry and remains responsible for the documented diagnosis and clinical judgement.
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Dictation is designed to be transcribed by a service running on infrastructure the customer controls, not by a third-party speech provider. It works only where that service has been deployed and connected for your tenant. The clinician reviews the transcript, which is added to the note as text.
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Yes. Vitals, allergies and history are available in the documentation workspace alongside the note and coding tools, helping the clinician review the context of the consultation.
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No. Signing freezes the note. A correction is a new addendum that the doctor signs, linked to the original note and carrying the reason for the change. Both remain on the record.
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Only the doctor who authored the note, and only with the signing permission. Care does not let another user sign on the author’s behalf.
Not answered here? Contact the team
NXH Flow