Clinical documentation

The Licensed Clinician records a clinical note against the consultation and names its author. The note has a type, text, signed date and status. Draft work remains distinguishable from Signed or Amended documentation. Observations also link to the visit, with a metric, numeric value, unit, observed date and the team member who recorded it. Together, these records let the practice read the clinical account in the context of the exact encounter.

An initial consultation can have a draft note while observations are still being entered. Before the visit is completed, the clinician can check that the note belongs to the right patient encounter, the observations use clear units and the author attribution is correct. The Clinical Reviewer can read these records during review, while the Clinical Coordinator can see the consultation state.

• Notes. Keep the narrative, type, author and signature state together on the consultation.
• Observations. Store each measured value with its unit, date and recorder rather than folding it into free text.
• Visit link. Use the consultation as the common reference for the evidence gathered on that visit.

Agree which note types the team will use and what a Signed or Amended note means in daily practice. Define how staff verify the encounter before recording evidence, especially when one patient has several visits. Agree a unit convention for each routinely measured metric, because a number without its unit can mislead the next reader. Assign responsibility for setting the signed date and for reviewing an amended note.

The documentation work should be tested with the roles that actually use it. Licensed Clinician can manage notes and observations. Clinical Reviewer has read access to examine the evidence. A coordinator responsible for closing the visit should know which clinical details to request from the clinician, without taking over note authorship.

Open an in progress consultation for a patient. The clinician creates a Draft note with a named author and records an observation with metric, value, unit and observation date. Check that both point to the same consultation. The clinician signs the note and enters the signed date, then asks the coordinator to move the consultation to awaiting review. Have the reviewer open the evidence and compare the note and observation to the patient and visit. Then rehearse an amended note and verify its status is visible separately from the originally signed state.

• Review queue — Find visits awaiting clinical evidence review.
• My consultations — Let a clinician find visits assigned to them before recording details.
• Consultation queue — Track the visit while note and observation entry is in progress.

Follow consultation and documentation and procedure support. Use the implementation guide to rehearse documentation handoffs.