Documentation and signature

Step by step

1. Record observations Licensed Clinician

   Licensed Clinician captures the metric, measured value, unit and observation date against the correct encounter. The recorded-by identity must resolve to the actual authorized person.

   • Retain attributed measurements
   • Updates Observations, Encounters, People

2. Prepare the clinical note Licensed Clinician

   Licensed Clinician creates the Draft note with its type, text and author. Keep the note attached to the encounter and available only within the relevant patient and professional scope.

   • Prepare Draft content under the real author
   • Updates Clinical notes, Encounters, People

3. Sign the attributed content Licensed Clinician

   Licensed Clinician reviews and authorizes the note under current authenticated professional authority. Signing records the signature date and changes Draft to Signed. Preserve the signed content against ordinary edits.

   • Record Signed and signed at under valid authority
   • Updates Clinical notes, Clinical privileges, Care team assignments, Consents
   ApprovalA person approves before the work moves on.

4. Resolve review and completion Clinical Reviewer or Licensed Clinician

   Clinical Reviewer handles eligible independent evidence review where required. Once the relevant documentation and review conditions are satisfied, the authorized encounter action records completion and its end date. Amendment uses an explicit correction path that preserves the signed source.

   • Resolve eligible review and permit encounter completion
   • Updates Clinical notes, Encounters, Clinical privileges, Care team assignments

Licensed Clinician

, Clinical Reviewer.

Licensed Clinician

Signs their eligible documentation; Clinical Reviewer handles independent review actions when the encounter requires them.