Encounter Documentation Norms
Clinical encounters occur in both inpatient and outpatient settings and are reflected in the Connect Care clinical information system (CIS) as a package of information related to a specific visit, admission or intervention.
"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.
The healthcare prescriber designated as the responsible prescriber for an encounter is accountable for signing encounter documentation and closing the encounter event.
Encounter Documentation Requirements
Some documentation norms reflect requirements set out in Alberta Health Services medical staff bylaws:
An ED Provider Note must be completed and appropriately signed within 24 hours of a patient visit to an emergency department.
An Admission History and Physical must be entered to Connect Care and appropriately signed for all inpatient encounters within 24 hours of admission, with provisions available for flagging a consultation note to serve as a H&P.
A Discharge Summary or Interfacility Transfer Note must be entered to Connect Care and appropriately signed for any inpatient encounter within 14 days from discharge.
An Operative Report must be entered to Connect Care and appropriately signed within 24 hours of the relevant surgical event.
All outpatient encounters must be documented, signed and closed in a timely fashion and, in any case, no longer than 3 weeks after the outpatient service event.