Visit documentation

Step by step

1. Receive the patient Front Desk Coordinator

   Front Desk Coordinator confirms the encounter and marks the scheduled visit Arrived.

   • Mark visit Arrived
   • Updates Encounters, Patients

2. Begin care Clinician

   Clinician moves the encounter to in progress and records when it starts.

   • Mark visit in progress and record start
   • Updates Encounters

3. Record the reason and measures Clinician

   Clinician enters the visit reason and observations against that encounter, including units and observation times.

   • Tie findings to this visit
   • Updates Visit reasons, Observations, Encounters

4. Write the note Clinician

   Clinician drafts the note under the encounter, checks author and content, then signs it and records the signing time.

   • Preserve Draft, Signed or Amended documentation
   • Updates Clinical notes, Encounters

5. Handle an order Clinician

   When medication is appropriate, the prescriber records a Draft prescription order, checks the dose instruction and signs or cancels it.

   • Record prescriber and signing decision
   • Updates Prescription orders, Clinical privileges

Front Desk Coordinator

Records arrival.

Clinician

Documents and signs clinical work.

Clinical Lead

Checks privilege evidence and later reviews the encounter.