Documentation review

Step by step

1. Draft note Licensed Clinician

   The Licensed Clinician records the note type, text, encounter and author.

   • Attributed draft documentation
   • Updates Clinical notes, Encounters, People

2. Record observation Licensed Clinician

   The clinician records a metric, numeric value, unit, observation date and recorder against the encounter.

   • Dated measurement and unit
   • Updates Observations, Encounters, People

3. Sign note Licensed Clinician

   The clinician checks the draft and records its signed status and date.

   • Signed note and signing date
   • Updates Clinical notes

4. Gather context Clinical Coordinator

   The Clinical Coordinator places the encounter in the awaiting-review state after care evidence is entered.

   • Awaiting-review state
   • Updates Encounters

5. Read evidence Clinical Reviewer

   The Clinical Reviewer opens the encounter and reads notes, observations, consent and relevant specialty records.

   • Evidence read with encounter context
   • Updates Clinical notes, Observations, Consents, Specimens, Pharmacy dispensations

6. Close handoff Clinical Coordinator

   The coordinator records the encounter's completed state after reviewing the visit record.

   • Completed visit state
   • Updates Encounters

Licensed Clinician

Creates and signs evidence; Clinical Reviewer reads it; Clinical Coordinator maintains the encounter handoff.