Encounters and notes

The Clinical Coordinator schedules an encounter for a patient and clinician, records its visit type, and tracks its current status. Arrival, start and end dates make the visit timeline visible. The encounter stays the common reference for observations, clinical notes, specimens, dispensations and charges. Staff can follow one visit without confusing it with another visit for the same patient.

The Licensed Clinician records measured observations with a metric, value, unit and observation date. A recorded-by person attributes the measurement. Clinical notes separately carry the author, type, text, signing date and status. A draft note can be edited during care. A signed note gives the reviewer a dated piece of clinical evidence. An amended status identifies a later change so the team can examine it during review.

• Visit coordination. The coordinator tracks scheduled and arrived visits, and checks the assigned clinician before care begins.
• Clinical evidence. The clinician adds observations and a note to the encounter, then signs the note when the documentation is ready.
• Review. The Clinical Reviewer examines the encounter and its evidence while the visit awaits review.

Decide which visit types the team uses, when arrival is recorded, and who can move an encounter into review. Agree what must be present before a note is signed: the author, note type, content and signing date should describe the actual visit. Establish how the reviewer handles a note that needs amendment. The reviewer communicates findings to the coordinator, who updates the encounter.

For an outpatient follow-up, the coordinator schedules the visit with its patient and clinician. At arrival, staff update its status. The clinician records a measured observation and drafts a note. After signing, the clinician asks the coordinator to place the encounter in review. The reviewer checks the signed note and visit timeline; the coordinator records completion after addressing findings. Any later correction remains recognizable as an amendment.

Use one patient with two visits close together. Place an observation and a signed note on the first visit. Confirm that the reviewer sees the correct patient, clinician and author, and that the second visit does not inherit evidence from the first. Move one visit through arrival, in-progress care and review. Confirm its start and end dates reflect the visit that was actually performed.

• Encounter schedule — Review scheduled and arrived visits with their patient, clinician and visit timing.
• Encounter status board — Find visits in progress and awaiting review by status.
• Signed clinical notes — Read attributed notes ready for review.

See encounter review, then follow-up care. The data model shows how each item points to the encounter.