Doctor notes with ICD-10 diagnoses in the patient record

What doctor notes in the CRM are

A doctor note in 95sales is a structured record of one visit, linked to the appointment and the patient record. The doctor opens the visit from their schedule, clicks Medical record and fills in the sections in order. Everything they write stays in the patient's history for the next doctor or anyone else with access.

Note sections:

1. Complaints: in the patient's words or with quick phrases from the template ("headache", "fatigue", "lower back pain").
2. History: the course of the illness and anything relevant.
3. Exam and vitals: blood pressure, pulse, temperature, SpO₂, weight and height as separate fields, plus the exam text.
4. ICD-10 diagnosis: one or more codes from the code list, plus free-text details.
5. Treatment plan: tests, procedures, treatment packages.
6. Recommendations: routine, monitoring, what to do if things get worse.
7. Follow-up: "in a week", "in 2 weeks" and so on. Once the note is finished, the CRM offers to book the follow-up right away.

ICD-10 diagnosis: how the doctor finds it

The diagnosis comes from the ICD-10 code list. The doctor starts typing a code ("I63") or words from the name ("stroke"), and the CRM shows matching entries. You can add several codes (the main diagnosis and secondary ones) and add details in text.

The ICD-10 code list is available in Ukrainian and Russian. There's no English version of the list yet, so English-language users see Russian code names.

Exam templates by specialty

A template in 95sales is a ready-made exam text plus a set of quick phrases for each section, so doctors don't type the same things over and over. The CRM picks the template from the doctor's job title in the staff directory, and the doctor can switch it by hand.

Template text only goes into empty sections. If the doctor has already written something and then switches templates, their text isn't overwritten. Custom templates for your clinic (other specialties, your own wording) are set up by the 95sales team during onboarding.

Draft, finish and PDF report

While the doctor works on a visit, the note is a draft and can be edited. When the doctor clicks to finish it, the note is locked: only its author or the clinic owner can change it. You always know who wrote what and when, and nobody else can rewrite a diagnosis after the fact. Every change goes into the activity log.

A finished note prints as a PDF consultation report: patient, visit date, doctor and title, complaints, history, vitals, exam, diagnosis with ICD-10 codes, treatment plan, recommendations and a line for the doctor's signature.

Who can see medical records

Only staff with the Medical records and care permission can see and write doctor notes, and the server enforces this, not just the screen. A doctor sees only their own patients. A sales rep, bookkeeper or location manager without that permission can't open the notes, even with a direct link.

The note text is encrypted with AES-256 using a separate key for each clinic, the same way as diagnoses, care logs and doctor comments. Only service fields stay readable in the database: which visit the note belongs to, who wrote it and whether it's a draft or finished. More on protection on the data security page, and on patient consent in consents and retention.

How this differs from an EHR

95sales CRM is not an EHR or practice management system, and doctor notes don't replace one where an EHR is required. The CRM has no link to Ukraine's national eHealth system, no e-prescriptions, e-referrals or sick notes, and no government medical forms. Doctor notes in the CRM are for clinics that want the exam next to the inquiry, the booking and the payment: private centers, rehab, aesthetic clinics. If your clinic has to report to eHealth, keep the EHR running alongside, and let the CRM handle sales, scheduling and money. More in the guide CRM vs EHR.

How notes connect to scheduling and money

A doctor note is one step in a single chain: inquiry → appointment → visit and note → Arrived and payment → follow-up. In My appointments, doctors see only their own visits, open the note from the visit and mark the patient as Arrived. If the note sets a follow-up, the CRM offers to book it right away. In the patient record, all doctor notes appear by date next to visits, payments and documents.

Who doctor notes in the CRM are for

• Medical centers with several doctors: each one writes from their own template, and management sees the patient's full history.
• Rehab centers: the rehab doctor's assessment with range of motion, muscle strength and scales, and a reassessment two weeks later.
• Private clinics with no EHR, or with an EHR used only for eHealth reporting: exams, diagnoses and reports live where sales and money do.

How to get started

1. We add doctors to the staff directory with their titles, which decide the template.
2. We turn on the medical records permission for the roles that need it (doctors, head nurse, management).
3. If needed, we set up custom templates for your clinic's specialties.
4. Doctors try it on 2–3 visits: draft, ICD-10, finish, PDF.
5. Management checks that only the right people see the notes, using "view as employee" (staff access).