Clinical evidence

A clinical note belongs to an encounter and names its author. The clinician records the note type and text, then uses the note’s state and signing date to distinguish a draft from a signed or amended entry. The encounter link matters: a note about an earlier episode should remain with that episode even if the same patient returns for another visit.

Observations also belong to encounters. Each observation records the measured metric, value, unit, time and person who recorded it. This lets a reviewer read a value in context instead of seeing an isolated number. A blood pressure or temperature example belongs only where the team uses that metric and unit in its own practice; the record itself remains a measured observation with an attributed recorder.

• Authored notes. The author, type, content, signing date and state show what was documented and whether it is still a draft.
• Measured observations. Metric, numeric value, unit and observation date describe what was measured and when.
• Episode context. Both forms of evidence point to the encounter, allowing a reviewer to examine the work behind an episode awaiting review.

Agree on note types that staff can apply consistently. Decide when a clinician signs a note and how amendments are handled after signing. A draft should remain distinguishable from signed evidence when a coordinator prepares the encounter for review. Give staff guidance on using the appropriate encounter, especially when a patient has several close visits.

For observations, agree on metric names and units before importing older records or beginning a pilot. A value without a unit can be hard to interpret, while the observed date should reflect the measurement rather than when someone later entered it. Decide which observations are expected for the pilot’s visit types and who reviews unusual values within your established clinical process.

A clinician opens an in-progress encounter, enters a note about the care given and records a measured observation with its unit and time. They review the draft, sign it and confirm that the author and encounter are correct. The coordinator moves the episode to review. Clinical Reviewer opens the encounter and examines the signed note and observation, then tells the coordinator whether the record is ready for completion. If a correction is needed, the note can be marked amended while the clinical team handles its review.

• Draft clinical notes — Find notes that still need the clinician’s signing decision.
• Encounter review queue — Read clinical evidence in the context of the episode awaiting review.

Follow encounter review and medication and evidence.