Clinical documentation

The clinician records a note with its type, text and author against an encounter. A draft remains visible in Notes Awaiting Signature until the author signs it. An observation records a metric, numeric value, unit, time and recorder against the same visit. A reviewer can inspect the evidence in the context of the encounter.

• Attribution. A note keeps its author and signing date beside its text.
• Measurement. An observation keeps its metric, value, unit, time and recorder.
• Encounter link. Both records point to the visit they describe.

The note and observation are separate records, even when they describe the same consultation. A draft note remains in the signature queue until the Licensed Clinician signs it. The observation captures a numeric result with its unit, so a reader does not have to infer what was measured. The Clinical Reviewer can compare both records with the encounter before the coordinator completes it. An amended note retains its own status for later review.

Agree which note types clinicians use and how they express measured observations with units. Decide how amendments are handled after a note has been signed. Train authors to use the correct encounter so later readers can trace the information to the visit.

Use a visit with a draft note and an observation whose unit is easy to confuse. Ask the Licensed Clinician to check the encounter link, metric and unit before signing. Include a wrong-encounter example so the team can practice correcting the reference before a reviewer relies on it. Agree who records an amendment and how a reviewer identifies it after the visit has ended.

On a consultation, record a measured observation and a draft note. Confirm both point to the same encounter and that the note names its author. Ask the clinician to review and sign the note. Reopen the case as a reviewer and compare the signed note, observation time and recorded value before the encounter is completed.

The Licensed Clinician signs the note after checking its author and content. Have the Clinical Reviewer open Encounters Awaiting Review and compare the note, observation and encounter. A note linked to another patient’s visit must be corrected before completion. Check the signature date and observation time on the records themselves rather than relying on a summary.

• Notes Awaiting Signature — Find draft notes with their encounter and author before the clinician signs them.
• Encounters Awaiting Review — Open visits awaiting evidence review and inspect the linked notes and observations.

See consultation intake, clinical review, follow-up coordination and service billing for the handoffs between these records.