Clinical documentation

An observation belongs to an encounter and names the person who measured it. A clinical note belongs to that encounter too, but has its own author and signature date. The Licensed Clinician can save a draft while gathering findings. Signing is a separate clinical decision after checking consent, assignment and the right professional privilege. If a signed note needs correction, use its Amended state so a reviewer can distinguish the later record from the original signature.

For an encounter awaiting review, open its draft note and observation. Compare the note author with the assigned clinician and the observation time with the visit. If consent was withdrawn before signature, keep the note in draft and ask the coordinator to resolve the consent record. Once the clinician signs, the reviewer can inspect the signature date and the linked evidence without editing the clinician’s text.

• Source. Keep note type, note text, author, signature date, metric, value, unit and observation time on the record that owns the work.
• Responsibility. Licensed Clinician starts from the relevant list and checks the linked record before acting.
• Handoff. Use the status and dates to decide what the next person should inspect.

Agree which note types clinicians use, how observations are recorded with units and timestamps, and when a draft is ready for signature. Name the consent purpose and Document privilege required for signature. Decide how amendments are reviewed without replacing the author or signature history. Rehearse a note that remains Draft because its consent expired, and let the clinician explain the next safe action.

Schedule an encounter and capture an observation with metric, value, unit, time and recorder. Have the Licensed Clinician draft a note with type and text. Check purpose-specific consent, active assignment and current Document privilege before the clinician signs. Then ask the Clinical Reviewer to inspect the same encounter and signed note. Repeat with a withdrawn consent and keep the note Draft. Repeat with a corrected note so the team sees the Amended state rather than losing the original attribution.

The note and observation can be reviewed together, but they remain separate records. A measurement can be corrected without changing the note author. When the reviewer asks for clarification, the Licensed Clinician should return to the original encounter and make the clinical decision there. The reviewer records the outcome through the review handoff rather than rewriting the clinician’s account.

• Draft Clinical Notes — Find unsigned encounter notes that need the clinician’s signature check.
• Encounters Awaiting Review — Open encounters whose evidence awaits a reviewer decision.
• Signed Consents — Check purpose and dates before the clinician signs.

Use the process walkthrough to rehearse the decision and the data model to check record links. The roles page explains the access responsibilities.