Clinical documentation guide

From DictaMed draft to the official medical record

Review, copy and finalise a temporary note in the authorised clinical system before its 24-hour expiry.

By DictaMedPublished 5 min read

The short answer

After checking the transcript and note, correct any clinical errors and copy the reviewed text into your organisation’s authorised medical record. Complete the usual patient identification, dating, signing and correction steps there. DictaMed keeps a temporary draft; it is not the permanent record.

Review before transfer

Before transferring the note, confirm that it belongs to the right encounter and describes the care provided. Check the clinical details that could change care, along with any pending results. If you changed the template or added audio, review the latest draft rather than an earlier copy.

Use your organisation’s clinical system

Paste the reviewed note into the approved patient record, then complete your organisation’s usual identification, dating, signing and amendment steps. DictaMed does not write directly into Medtech or another hospital record in this workflow, and pasting text alone may not finish the documentation task.

Before leaving the source application, confirm the note appears in the correct patient encounter and that formatting has not altered lists, units or negations. The final record is the version your workplace retains.

Understand the temporary draft window

DictaMed encrypts temporary transcripts and notes and schedules clinical drafts to expire within 24 hours of creation. The practitioner can delete a draft sooner. Do not rely on the draft as an archive or as a substitute for transfer to the official record.

Follow workplace policy for retention and correction of the permanent medical record. If the draft has expired before transfer, reconstruct the note from verified clinical sources under that policy rather than relying on memory alone.

Common questions

Is a DictaMed note the legal clinical record?

No. It is a temporary draft until reviewed and entered into your authorised clinical system.

Can I delete the draft after copying?

Yes. Confirm the correct note is safely in the authorised record, then use the available deletion action if desired.

Sources and product details

These guides describe DictaMed’s current workflow and general documentation principles. Follow your workplace policy and use clinical judgement for each patient.

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