Clinical documentation

Step by step

1. Open the visit Licensed Clinician

   Licensed Clinician selects the patient's in progress encounter and checks the assigned clinician and visit type.

   • Check patient and visit identity
   • Updates Encounters, Patients

2. Record observations Licensed Clinician

   The clinician records the metric, value, unit, time, and recorder. Each observation refers to the encounter.

   • Preserve metric, value, unit, and recorder
   • Updates Observations, Encounters, People

3. Write the note Licensed Clinician

   The clinician enters the note type and text as a Draft clinical note with an author and encounter.

   • Attribute draft text to its author
   • Updates Clinical notes, Encounters, People

4. Sign or amend Licensed Clinician

   The author records the signing date and changes the note to Signed. If documentation changes later, Amended remains a distinct state.

   • Distinguish signed and amended documentation
   • Updates Clinical notes

5. Prepare review Clinical Coordinator

   Clinical Coordinator marks the encounter awaiting review so Clinical Reviewer can read the linked clinical evidence.

   • Put the visit before the reviewer
   • Updates Encounters, Clinical notes, Observations

6. Coordinate follow-up Licensed Clinician

   The team assigns a care task to a patient and person when a later action is needed, with a due date and status that can be followed after the visit.

   • Assign work and its due date
   • Updates Care tasks, Patients, People

Licensed Clinician

Records evidence; Clinical Coordinator coordinates review and follow-up; Clinical Reviewer reads the care record.