Care evidence review

Gather visit notes, observations and consent before completing the encounter.

Step by step

Capture care evidence Licensed Clinician

The Licensed Clinician enters a note and observations against the active encounter, naming the author and recorder.
- Attribute note and measurement to the visit
- Updates Clinical notes, Observations, Encounters
Sign documentation Licensed Clinician

The clinician reviews the note content and signs it, recording the signing time.
- Draft moves to Signed with signing time
- Updates Clinical notes
Place visit in review Clinical Coordinator

The Clinical Coordinator receives the clinician's handoff and marks the encounter as awaiting review.
- In progress moves to awaiting review
- Updates Encounters
Read the visit record Clinical Reviewer

The Clinical Reviewer reads the encounter, notes, consent, observations and any specialty records; the coordinator resolves the operational handoff.
- Inspect linked care evidence
- Updates Encounters, Clinical notes, Consents, Observations, Specimens, Pharmacy dispensations
Complete encounter Clinical Coordinator

The Clinical Coordinator records the end time and marks the encounter completed when the record is ready.
- Awaiting review moves to Completed with end time
- Updates Encounters

And how to keep it from happening.

A note can be signed on a different encounter than the observation. Check the visit reference on both records.
A numeric observation without the correct unit is hard to interpret. Confirm the metric, value, unit and observation time together.
A signed consent document can have expired or been withdrawn. Read its current state and expiry for the actual purpose.

Start free, then use Proto to change fields, steps and approvals before your team goes live.