Medication and clinical evidence

Keep medication entries, notes, observations and specimen evidence with an encounter.

Step by step

Open the episode Licensed Clinician

Licensed Clinician selects the current encounter and checks the patient and clinician context.
- Confirm the current episode
- Updates Encounters, Patients
Record medication Licensed Clinician

The clinician enters medication, quantity, unit, lot and authorizing person when that work occurs.
- Identify medication details and authorizer
- Updates Medication administrations, People
Record observations Licensed Clinician

The clinician enters the metric, value, unit, observation time and recorder for measured evidence.
- Attribute measured evidence
- Updates Observations, People
Document the care Licensed Clinician

The clinician writes an attributed note, reviews the draft and records its signing state.
- Keep signed or draft documentation visible
- Updates Clinical notes
Track specimen collection Licensed Clinician

When the episode involves a specimen, the clinician records its type, collection date, accession and progress status.
- Follow collection and accession state
- Updates Resident care plans
Examine the episode Clinical Reviewer

Clinical Reviewer reads the relevant records together before the coordinator completes the encounter.
- Review associated evidence
- Updates Encounters, Clinical notes, Observations, Medication administrations, Resident care plans
ApprovalA person approves before the work moves on.

Licensed Clinician: Enters evidence.
Clinical Reviewer: Examines it.
Clinical Coordinator: Routes the encounter for review.
Clinical Governance Administrator: Maintains professional privilege information.

Start free, then use Proto to change fields, steps and approvals before your team goes live.