Encounter Documentation Norms

What is it?

Clinical encounters occur in both inpatient and outpatient settings and are managed in Connect Care as a package of information related to a specific visit, admission, interaction or intervention. Key encounters (e.g., emergency or outpatient visits, admissions) must include appropriate documentation of information gathered during and communicated after the encounter. 

Encounter documentation norms relate to minimum requirements for an encounter to be "closed" with appropriate documentation, or otherwise completed within an acceptable time frame:

Emergency encounters 

Inpatient encounters

Outpatient encounters

Why does it matter?

"Opening" and "Closing" encounters affects what other Connect Care users can see or do, especially in outpatient contexts. If, for example, a note is kept in a "pended" or incomplete state, it may not be possible for persons other than the author to view vitally important information. Accordingly, all Connect Care users need to manage encounters in a way that does not unduly limit access to information or functions needed by others.

Primary caregivers, as well as specialists participating in outpatient care, need to be aware of the actions and accountabilities of others. Their effectiveness is directly impacted when key documentation is missing or unsigned (or co-signed to validate trainee work) or delayed. Connect Core norms reflect the communication pace of modern practice, and the capacity of modern digital health records to keep pace. 

Summative encounter documentation is the primary method for communicating plans and accountabilities across the continuum of care. Standardization of the content, format and timeliness of encounter documentation is the most powerful determinant of informational continuity. 

The length of time between discharge and receipt of summative documentation correlates with increased risks for readmission and other post-discharge adverse events.

Alberta Health Services staff bylaws, as well as CPSA professional standards, set absolute outer bounds for encounter documentation timeliness:

Who is responsible?

The healthcare prescriber designated as the responsible prescriber for an encounter is accountable for signing encounter documentation and closing encounter events. 

Accountable prescribers received deficiency notifications via the Connect Care In Basket.

How is it done?


The only way to satisfy encounter documentation norms is to complete and sign the required documentation type within the appropriate time interval. A number of tools facilitate taking timely action:

Sharing before Signing

All of the above highlighted summative documentation types are shared with Alberta's Electronic Health Record (Alberta Netcare Portal, twice daily) and capable Community Electronic Medical Records (up to 4 times daily). Effectively, summaries are received the same day they are signed.

The trigger for sharing is document signing or (required) cosigning. To avoid duplicate document challenges in receiving systems, it is important that authors "Share" documents, leaving them to be "Signed" just once by the accountable prescriber. That there may be outstanding laboratory test results is not a justification of signing-then-re-signing encounter documentation. Rather the summary transition plan should specify who is accountable for following up investigations unreported at discharge.

How is compliance promoted?

Feedback about adherence to clinical documentation minimum use norms is provided to prescribers using In Basket charting deficiency messages. These focus on whether required summative documentation has been completed within expected time frames.

Select encounter documentation norms appear within Minimum Use Norms and Meaningful Use Norms dashboards, available in the Hyperspace "Dashboards" workspace. Metrics are added as they become available and validated for AHS contexts:

Derivation of these metrics is explained further in the Connect Care Builder Handbook, with links to data quality definitions.