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- Medical Coding System
- Process
- Encounter documentation
Encounter documentation
Attribute clinical notes and observations to the visit before review.
Step by step
-
Start encounter Clinical Coordinator
The Clinical Coordinator records Arrived and in progress as care begins, with the start time on the encounter.
- Show the visit's active state and start time
- Updates Encounters
-
Document care Licensed Clinician
The Licensed Clinician writes a note against the encounter, identifies its type and signs it when ready. Measurements are recorded separately with value, unit, time and recorder.
- Attribute text and measurements to the visit and author
- Updates Clinical notes, Observations, Encounters, People
-
Review evidence Clinical Reviewer
The Clinical Reviewer reads the encounter, signed notes and observations while the visit is awaiting review. The reviewer can also inspect linked specimen and dispensation records.
- Bring the visit's supporting records into review
- Updates Encounters, Clinical notes, Observations, Coding reviews, Code assignments
-
Complete encounter Clinical Coordinator
The team records the end time and Completed state once the visit's work and review are finished.
- Record the end time and completed state
- Updates Encounters
Who does what
Roles and permissions- Licensed Clinician
- Records care; Clinical Reviewer inspects evidence; Clinical Coordinator tracks the encounter and its completion.
Set up Medical Coding System your way.
Start free, then use Proto to change fields, steps and approvals before your team goes live.