Clinical documentation

The clinician records an observation with its metric, value, unit and observation date, tied to the encounter. A clinical note has a type, text, author and signing date. These links make it possible to read what was measured and who documented it for the visit being reviewed. A draft note stays distinguishable from a signed note; an amended note has its own state.

• Anchor the record. Use the encounter to locate the visit the Licensed Clinician is documenting.
• Capture the evidence. Record each measurement with its value, unit and observation date.
• Check the handoff. Keep the note author, signing date and Draft, Signed or Amended state visible to the reviewer.

A Clinical Reviewer can inspect the encounter and its evidence before the coordinator completes the visit. The reviewer sees the patient and clinician through the encounter, then reads notes and observations in that context. A number without its unit or an observation attached to the wrong encounter can change its meaning. Check those details at the point of capture, while the visit is fresh.

Agree who may author and sign notes, how the team uses note types, and when an amendment is appropriate. Define the metric and unit conventions used in your clinic. The team should also agree how a reviewer raises a correction to the clinician and how the corrected evidence is checked before the encounter is marked complete.

Use a consultation with a measured value and a clinical note. Enter the observation with its unit and the correct encounter. Create the note as a draft with the licensed clinician as author, then sign it with a signing date. Ask the reviewer to open the visit and confirm that the note, measurement, author and dates all belong to the same encounter. Change the note to Amended only when the clinician has reviewed the correction, and check its author and signing date again.

• Notes needing signature — Open draft notes so the author can finish and sign the visit documentation.
• Visits awaiting review — Read the visit evidence and check that each measurement and note belongs to this encounter.

Follow the connected records in the operating process and agree the decision points before the first live visit. Use implementation to prepare sample cases with the team. Return to the data model when mapping existing patient and encounter records. The team should confirm that each role can reach the records needed for its own part of the handoff.