Encounter documentation and review

Step by step

1. Schedule encounter Clinical Coordinator

   The Clinical Coordinator records patient, clinician, visit type and scheduled date. The status starts at Scheduled.

   • Visit assigned to a patient and clinician
   • Updates Encounters, Patients, People

2. Begin visit Clinical Coordinator

   The coordinator records arrival and the start date while the Licensed Clinician begins care. The encounter moves through Arrived and in progress.

   • Arrival and start recorded
   • Updates Encounters

3. Document care Licensed Clinician

   The clinician records observations and drafts a clinical note against this encounter, then signs it with an author and signing date.

   • Attributed measurements and signed note
   • Updates Observations, Clinical notes, Encounters

4. Review encounter Clinical Reviewer

   The Clinical Reviewer examines the signed note and visit evidence while the encounter is awaiting review. The reviewer tells the coordinator whether the evidence needs correction before completion.

   • Evidence assessed before completion
   • Updates Encounters, Clinical notes, Observations

5. Complete visit Clinical Coordinator

   The encounter moves to Completed and its end date closes the visit timeline. Follow-up tasks and charges can then be reviewed in their own records.

   • Final status and end date recorded
   • Updates Encounters

Clinical Coordinator

Coordinates the visit, Licensed Clinician records care, and Clinical Reviewer decides whether the evidence is ready for completion.