All applications611

Find your application

611 applications

Open full catalog

Browse applications by category or open the full catalog.

Eye Care / Optometry

Features

Industries

Reference

More

Start now
  1. Eye Care / Optometry
  2. Process
  3. Care documentation
Process · Care documentation

Care documentation

The encounter is the common reference for what happened during care. Each clinical note has an author and signing state. Each observation has a metric, value, unit, time and recording person. A specimen or medication event gets a separate linked record so the reviewer can distinguish what was measured, collected or dispensed.

Start now Download Proto

Step by step

  1. Run encounter Licensed Clinician

    Clinical Coordinator records that care has started on the scheduled patient visit; Licensed Clinician begins the examination.

    • Establishes the active care episode
    • Updates Encounters

  2. Record care Licensed Clinician

    The clinician records an observation and clinical note in the encounter context. The note changes from Draft to Signed when documentation is complete.

    • Preserves attributed narrative and measurements
    • Updates Clinical notes, Observations

  3. Track specimen Licensed Clinician

    When material is collected, the clinician records the specimen type, date and accession reference. Its status follows its actual handling.

    • Follows ordered, collected and received material
    • Updates Refraction records, Encounters

  4. Record dispensation Licensed Clinician

    When medication is dispensed, the clinician records medicine, lot, quantity, unit and authorizing person.

    • Captures medication and authorization reference
    • Updates Lens orders, People

  5. Review encounter Clinical Reviewer

    Clinical Reviewer checks the linked care evidence and approves completion when the record is ready.

    • Communicates the review decision for coordinator follow-through
    • Updates Encounters, Clinical notes, Observations
    ApprovalA person approves before the work moves on.

Where it usually breaks

And how to keep it from happening.

  • A number without a consistent unit cannot be compared reliably. Agree metric and unit language before live entry.
  • A note left in draft is not signed clinical documentation. Keep it visible in Unsigned notes.
  • A specimen status should follow receipt and testing evidence. The accession reference helps staff match external lab information.
  • The lot recorded for a dispensation should be checked against the package used, not inferred from a care note.

Who does what

Roles and permissions
Licensed Clinician
Captures care evidence.
Clinical Reviewer
Examines it.
Clinical Coordinator
Follows visit status.
Clinical Governance Administrator
Maintains the clinician privilege record.

Set up Eye Care / Optometry your way.

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

Start now Download Proto

How to get started