Clinical documentation

The Clinician records why the patient came in against the active encounter. Observations capture a metric, numeric value, unit, observation time and the person who entered it. A note records its type, text, author and signing state. Keeping all three under the same encounter helps the Clinical Lead read the visit as one case. The time on an observation and the signing time on a note explain when those parts of care were recorded.

A note begins Draft. The author reviews its content, then moves it to Signed and records the signing date. If a signed note needs correction, Amended distinguishes the revised state from the original drafting phase. The status is useful for a review queue, but the team should still open the text and associated observations before completing a visit. A signed note does not by itself finish the encounter.

• Reason. A visit reason connects the patient’s stated purpose to this encounter.
• Measures. Observations retain numeric values, units and recorder identity.
• Narrative. Notes retain author, type, text, signing time and state.

Agree which note types the clinic uses and what information clinicians put in note text. Decide who verifies an observation’s unit when it is unusual. Define the Clinical Lead’s review of signed notes and how an amendment is handled after a visit has been completed. Record a visit reason for each encounter rather than carrying forward a previous visit’s reason without review.

A patient arrives for a follow-up consultation. The Clinician opens the in progress encounter, records the visit reason, then records an observation with its unit and time. The Clinician drafts a note, checks that it refers to today’s finding, and signs it. The encounter moves to awaiting review. The Clinical Lead opens the same encounter, compares the note with the reason and observation and approves completion. If the note needs a correction, the clinician records the Amended state and the reviewer checks the revised case before finishing. This rehearsal exposes accidental documentation on a prior encounter.

• Draft Clinical Notes — Find notes that still need an author decision.
• Encounter Review Queue — Read the encounter and its linked documentation.
• Visit Status Board — See where a documented visit sits in the clinical flow.

Follow visit documentation for entry and clinical review for the completion decision. Check the data model for the encounter links.