Encounters and observations

An encounter ties a patient and clinician to a scheduled time, visit type, start time, end time and working status. The schedule lets the care team see what is planned. Arrival means staff have verified patient identity and current purpose-specific consent. In progress means the team is documenting care. Awaiting review identifies a handoff before completion. Completed requires an actual end time and the necessary documentation and follow-up checks.

Observations hold point-in-time measurements taken during the encounter. Each observation records the metric, value, unit, observed time, encounter and person who recorded it. Keep these separate from transmitted device readings: an observation belongs to a care encounter, while a remote reading belongs to a device enrollment. A clinician can compare them in context without turning one into the other.

• Schedule. Care Coordinator selects the patient, clinician, visit type and planned time.
• Document. Monitoring Clinician records arrival, observations and the clinical note.
• Close. The clinician resolves outstanding care tasks and records when the encounter ended.

Choose how visits are scheduled and who verifies identity at arrival. Define which purpose-specific consent applies to each visit type, and what evidence staff must see before recording arrival. Decide which observations the team captures during the visit and which units they use. Make the distinction between a device transmission and an encounter measurement clear in training, especially when both occur on the same day.

Agree who handles an encounter awaiting review, how an unsigned note is returned to its author, and how a care task is resolved before completion. A cancelled appointment should remain distinguishable from a completed one. A visit that started but lacks its actual end time should remain open for correction by the right clinician. These are ordinary operating decisions to rehearse with a scheduled, cancelled and completed example.

A patient with an assigned clinician arrives for a scheduled review. Care Coordinator confirms identity and signed consent, then records arrival. Monitoring Clinician begins the encounter, measures a value and records it as an observation with unit and time. The clinician drafts a note, assigns a care task and sends the encounter for review. Once the note is signed and the task is resolved, the clinician records the actual end time and completes the encounter. Anyone reading the chart can distinguish the visit measurement from the earlier transmitted readings.

• Encounter workboard — See scheduled, arrived, active and awaiting-review visits by status.
• Upcoming encounters — Check the patient, clinician and planned time before the visit.
• Encounters awaiting review — Find visits whose documentation still needs attention.

Read consent to encounter and encounter to signed note. Use the data model to plan source mapping.