Documentation and review

Step by step

1. Open the encounter Licensed Clinician

   Licensed Clinician selects the patient's current encounter and checks its visit state and assigned clinician before entering evidence.

   • Identify the current care episode
   • Updates Encounters, Patients

2. Record observations Licensed Clinician

   The clinician adds each metric with value, unit, time and recorded person. The encounter reference keeps it with the right care episode.

   • Preserve measurement, unit, time and recorder
   • Updates Observations, Encounters, People

3. Draft the note Licensed Clinician

   The clinician records note type and text, with the named author. Draft identifies work that can still be completed.

   • Attribute a clinical statement to its author
   • Updates Clinical notes, Encounters, People

4. Sign the note Licensed Clinician

   When documentation is ready, the clinician records the signed date and Signed state. An amendment is identified by Amended status.

   • Record signed date and documentation state
   • Updates Clinical notes

5. Review the case Clinical Reviewer

   Clinical Reviewer reads the encounter, note and observations while the visit is awaiting review. The team agrees how a concern is returned to the treating clinician.

   • Inspect linked evidence before close
   • Updates Encounters, Clinical notes, Observations

Licensed Clinician

Writes notes and observations; Clinical Reviewer reads them; Clinical Coordinator maintains the encounter state and patient connection.