When generating notes from transcripts in PatientNotes, it’s important that your documentation reflects only what was actually assessed, observed, or discussed. This keeps notes accurate, reduces filler content, and avoids assumptions.
Why this matters
Including information that wasn’t covered in the session can lead to:
Inaccurate clinical records
Confusion or misinterpretation by other clinicians
Compliance and medico-legal risk
Control what appears in your notes: “Always” vs “If Discussed” (Header or Context)
In Templates, you can now decide whether a section is included automatically or only when it’s discussed — and you can apply this to either:
The Header (the section title, e.g. Medications), and/or
The Context (the instruction text that tells PatientNotes what to write in that section)
This means you can keep your template structure consistent, without needing to edit the underlying prompt.
What the two options mean
Always
Choose Always if you want the header or section content to appear every time, even if it wasn’t discussed.
This is useful when:
Your organisation requires a complete template every time
You want to show that items were not assessed / not discussed
You’re working to a strict documentation standard (e.g. audits, medico-legal, minimum dataset requirements)
If Discussed
Choose If Discussed if you only want sections to appear when they’re actually mentioned in the consult.
This is useful when:
You want notes to be concise and only reflect what was assessed
You want to avoid empty sections and “filler” content
You prefer documentation that mirrors the consult exactly
Common ways to use this (best practice examples)
Option 1: Header = Always, Context = If Discussed
Use this when you want the structure visible, but only want content added when relevant.
Example:
Medications header always shows
Medication details only appear if medications were discussed
This is ideal if you want a consistent note format while still keeping content clean.
Option 2: Header = If Discussed, Context = If Discussed
Use this when you only want the entire section to appear if it came up in the consult.
Example:
If medications weren’t discussed, the Medications header won’t appear at all
This is ideal if you want notes to show only what was assessed/discussed.
Option 3: Header = Always, Context = Always
Use this when every section must be present every time, regardless of what was covered.
Example:
Presenting Complaint always appears
Content always appears (and may include “Not assessed / Not discussed” style outputs depending on your template setup)
This is best for organisations that require all fields completed or explicitly acknowledged.
Why you might choose one approach over another
Some clinicians prefer notes that only show what was discussed or assessed, keeping documentation short and highly relevant. Others (or some organisations) require all fields to be included every time — even if the answer is “not assessed” — to meet policy, compliance, or medico-legal standards.
PatientNotes now supports both approaches, so you can match the template behaviour to the needs of you and your organisation.