Clinical care

Clinician records clinical notes against an encounter. A note carries its type, text, author, signed time and status. Draft work can be completed and signed when the clinician is ready to stand behind it. An Amended note needs to remain distinguishable from the original signed state. The care team should agree who may make that change and how a colleague will understand the reason through its operating practice.

Observations attach a metric, numeric value, unit, observation time and recorder to the same encounter. The unit matters: a bare value is difficult to interpret at handoff. A care task has a task description, patient, assignee, due time, completion time and status. These records give the next person concrete work to finish without turning a clinical note into a private reminder list.

• Notes. Clinician writes and signs documentation against the active encounter.
• Measurements. The recorder enters the metric, value, unit and observation time.
• Follow-up. A named assignee tracks an open task through completion or escalation.

Agree local note types and who can sign or amend notes. Decide which measurements staff record, using a consistent metric and unit vocabulary. Set expectations for task descriptions and due times so the assignee knows what completion means. Clinical Lead should define when a task is escalated and who handles that escalation. Check that the person assigned to clinical work has the relevant care team assignment and privilege for that work.

A clinician starts an encounter and records an observation with its unit and time. They write a draft note about the assessment and create a follow-up task for another care team member, with the patient and due time attached. The assignee opens My care tasks, performs the requested work and records completion. The clinician signs the note after checking the result and the recorded observations. If the task cannot be completed on time, the assignee marks it Escalated so the clinical lead can respond.

The next shift reviews the encounter, the signed note, the observation time and remaining open tasks. A completed task should carry its completion time; merely writing that work is done in a note leaves the task queue misleading. If a signed note must be corrected, use the Amended state deliberately and preserve the clinical meaning of the earlier record in the team’s review process.

• Open care tasks — Review outstanding and escalated follow-up by patient and assignee.
• My care tasks — Let each assignee find their own due work.
• Active encounter workboard — Return to the encounter holding the care record.

See care delivery and diagnostic review.