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  1. OT / Surgery Scheduling
  2. Process
  3. Document and review care
Process · Document and review care

Document and review care

Record visit timing, clinical notes and observations before completion.

Step by step

  1. Arrival Clinical Coordinator

    Clinical Coordinator confirms the patient has arrived for the scheduled encounter.

    • Identifies the visit taking place.
    • Updates Encounters
  2. Care start Clinical Coordinator

    Clinical Coordinator records the visit as in progress and the actual start date.

    • Records active care and timing.
    • Updates Encounters
  3. Observation capture Licensed Clinician

    Licensed Clinician selects the encounter and records each metric, value, unit and observed date.

    • Attributes measurements to the visit and recorder.
    • Updates Observations, Encounters
  4. Note preparation Licensed Clinician

    Licensed Clinician writes the note under the same encounter with a type and Draft status.

    • Creates attributed draft documentation.
    • Updates Clinical notes, Encounters
  5. Note signature Licensed Clinician

    Licensed Clinician signs the note and records its signed date.

    • Records the signed state and date.
    • Updates Clinical notes
  6. Encounter review Clinical Reviewer

    Clinical Reviewer reads the encounter, note and observations while the visit is awaiting review; Clinical Coordinator completes the encounter after the handoff.

    • Examines evidence before completion.
    • Updates Encounters, Clinical notes, Observations
Licensed Clinician
Records notes and observations; Clinical Reviewer reads the evidence; Clinical Coordinator manages the encounter state; Admin supports access setup.

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