Clinical evidence

Screening Staff capture observations with a metric, numeric value, unit, observed date and recording person. They also write clinical notes with a type, text, author and signature date. Both records point to a specific screening camp. This gives the Screening Reviewer a way to inspect evidence from the right encounter rather than reading an unattached note or a value copied into a general participant record.

A note can be Draft, Signed or Amended. Its status and signed date should agree with the action taken by its author. An observation has no separate review state, so the reviewer should inspect the metric, unit, value, date and recorder in the context of the camp. The Clinical Notes and Details page supports work on the notes. The overview page shows recent specialty evidence alongside the operational state of camps.

• Measure in context. Put each observed metric and unit on the camp where the measurement took place.
• Attribute the note. Keep the author and signed date with the clinical text so another staff member can distinguish a draft from a signed entry.
• Prepare the review. Use the camp’s awaiting review state to gather the linked records a reviewer needs to inspect.

The reviewer has read access to the clinical records. Staff manage their captured evidence. The coordinator manages the camp status, so the handoff needs an agreed operational check before the camp is marked Completed.

Define the metrics and units your screening team will enter. Decide who checks an implausible value and how the person who recorded it corrects it. Agree when a note is ready to sign and what an amendment means for an earlier signed version. A signature date records a point in time; the team should decide how to handle a note that is still Draft when the camp reaches review.

The reviewer needs a clear expected set of evidence for each screening type. Write that checklist with the team during implementation. If specimens or dispensations are part of a particular screening, reviewers should know where those records appear and which status or fields they inspect. Keep clinical interpretation with the qualified person; the record supplies evidence and attribution.

Rehearse a camp with one measurement and one note. Screening Staff enter the metric, value, unit and observed date, then write a Draft note linked to the same camp. Have the author sign the note and confirm the signed date. Move the camp to awaiting review and ask a Screening Reviewer to locate the note and observation from the camp. Change the note to Amended in a separate rehearsal and check that the team understands which text is current before completion.

• Draft clinical notes — Camp notes that still need author attention before review.
• Awaiting camp review — Screening records whose linked evidence is ready for inspection.

See evidence review and specimen handling.