Encounter documentation

A visit can be scheduled before its clinical work begins. The Clinical Coordinator records the patient, clinician, visit type and scheduled time, then updates the encounter as the patient arrives and work starts. Actual start and end times describe the visit that happened. Keeping those events clear helps the team distinguish a patient still waiting from a visit awaiting clinical review.

Licensed Clinician records the clinical note against that encounter and keeps authorship visible. Measurements belong to the same visit with their metric, value, unit, observation time and recorder. A colleague reviewing the encounter can read the note and the recorded measurements together. The record supports professional review without turning a measured value into an automatic clinical conclusion.

• Visit progress. Clinical Coordinator maintains Scheduled, Arrived, in progress, awaiting review, Completed or Cancelled as the encounter moves through the center. Record the actual start and end when they occur. Keep a cancelled appointment distinct from a visit that finished and received review.
• Attributed notes. Licensed Clinician records the note type and text with the author. Draft remains distinguishable from Signed. When a signed note needs a documented correction, use Amended and follow the center’s agreed correction procedure so the reviewer understands the change.
• Measured observations. Record the metric with its value and unit at the time of observation. The recorder and encounter identify who entered it and which visit it belongs to. Review differently named metrics or different units before comparing measurements across visits.

Agree which visit types the center uses, who records arrival and who closes the operational encounter after review. Choose note type labels and a signing procedure that the clinicians can follow. Define the measurement names and units used in the pilot so equivalent measurements can be found together without changing their clinical meaning.

Clinical Reviewer reads the care evidence and communicates the outcome to Clinical Coordinator. Agree that handoff explicitly, including how a reviewer returns an incomplete record for attention. Configure the permitted completion action with the center’s decision owner and rehearse it. A completed encounter should reflect the actual reviewed visit, with outstanding follow-up assigned separately.

Rehearse a consultation that has started but still has a Draft note. Licensed Clinician enters an observation with its unit and signs the note after checking the author and encounter. Clinical Coordinator places the encounter in awaiting review. Clinical Reviewer reads the evidence and communicates the decision; the coordinator then records completion and the actual end time. Include another visit that was cancelled before arrival and confirm that it remains easy to distinguish in the daily review.

• Encounter schedule — Review scheduled visits alongside their actual start, end and current state.
• Notes awaiting signature — Find clinical documentation still in Draft before the review handoff.
• Encounter review queue — See encounters waiting for the Clinical Reviewer’s decision and operational completion.

Follow intake to encounter review and patient follow-up.