Clinical records

The Licensed Clinician records a clinical note under the encounter, identifies its type and writes the care text. The author link makes clear who documented the visit. A note can be a draft, signed or amended; the signing date marks the completed documentation. Observations sit beside notes as measured values with a metric, unit, observation date and recording person.

For an eye care visit, a clinician may record measurements that fit the clinic’s examination practice as observations. The team should use a controlled naming convention for metrics and units, because a number has little meaning without both. The note provides narrative context while each observation holds a single measured value.

• Attributed narrative. The note retains its encounter and author, allowing a reviewer to read documentation in the right visit context.
• Measured findings. Each observation records a metric, value, unit and time with the person who took it.
• Review readiness. Draft notes remain visible until signing, so the care team can distinguish unfinished documentation from signed evidence.

Agree the note types the clinic uses and when signing is required. Decide who can amend a signed note and how the clinic explains that amendment to reviewers. Establish the metric and unit vocabulary for common measurements. Decide whether the person recording an observation may differ from the visit clinician, and ensure both names are meaningful in the clinic’s care policy.

The governance administrator should verify the relevant clinician privilege before the team relies on signed documentation. The Clinical Reviewer can inspect the records, but a review decision belongs to the clinic’s agreed encounter review path. Access to narrative notes should be rehearsed with each role before live use.

During an eye examination, the clinician records a measured observation with its unit and a note explaining the assessment. The observation points to the encounter and the person who recorded it. The clinician leaves the note in draft while completing documentation, then signs it when ready. The Unsigned notes screen keeps the draft visible until that action is done.

When the encounter reaches review, the reviewer examines the signed note and the observation in the same visit context. If a note needs correction after signing, the care team records an amendment rather than treating the original signed event as if it never occurred. The coordinator can then close the visit after the reviewer decides that the record is complete.

• Unsigned notes — Draft notes by encounter and author that still need attention.
• Encounters awaiting review — Visits whose linked documentation needs the reviewer’s decision.

See care documentation and clinical review.