Encounters and clinical evidence

An encounter connects the patient and clinician to a scheduled time, visit type, actual start and end, and a visible status. Clinical Coordinator can plan the visit and see whether it is Scheduled, Arrived, in progress, awaiting review, Completed, or Cancelled. Licensed Clinician records clinical notes and measured observations against the encounter. This gives reviewers a specific care episode to inspect instead of a loose collection of text.

Notes retain their author, note type, text, signing date, and Draft, Signed, or Amended status. Observations retain a metric, value, unit, observation time, and recorder. The distinction matters: a measured value should keep the unit in which it was entered, while a note should keep attribution to the person who wrote it. A reviewer can trace both back to the encounter and its patient.

• Visit plan. Clinical Coordinator selects patient, clinician, visit type, and scheduled date.
• Clinical entry. Licensed Clinician writes notes and records observations during care.
• Review. Clinical Reviewer reads encounter and linked evidence while the coordinator follows the visit’s status.

Set a shared convention for visit types and note types. Decide when staff record arrival, actual start, and actual end, including a visit that is cancelled after scheduling. Agree who checks that the right patient was selected before documentation begins. A signed note carries a signing date; an amendment should retain a distinct status so the team can see that the documentation changed.

Clinical Reviewer has read access to the care-domain records. That role can examine a case marked awaiting review, while Clinical Coordinator manages the encounter record. During setup, agree how a reviewer communicates a finding to the coordinator and how the team decides when the visit can be marked Completed. Keep the human review visible in the operating practice.

Schedule a visit for an existing patient and choose its clinician. At arrival, Clinical Coordinator updates the visit and marks it in progress when care begins. Licensed Clinician records a measured observation with its unit and time, then writes a Draft note. Before the note is signed, inspect the patient and encounter link. The clinician signs the note with its date; Clinical Coordinator moves the encounter to awaiting review. Clinical Reviewer can read the signed note and observation in the context of the same visit.

For a second case, change a note after signing. Use the Amended state and keep the author clear. The team should be able to tell a normal completed visit from one where documentation needs follow-up. A specimen or dispensation created during the visit also belongs to this encounter, so the specialty team should confirm the link before entering a lot or accession number.

• Encounter Schedule — See upcoming and arrived visits with patient, clinician, and visit times.
• Encounters Awaiting Review — Read visits ready for clinical evidence review.
• Notes Awaiting Signature — Find draft notes that still need their author to sign.

See encounter intake and clinical documentation.