Skip to main content
The Patient Encounter is the main clinical record for every home visit. It is where the caregiver documents what the patient reported, what was found during the assessment, any medicines prescribed, and any tests ordered. Think of it as the written record of everything that happened during the visit - something that anyone on the care team can look at later to understand what was done and why.

​
Before You Start

  • The patient must have a booked visit (a Patient Appointment must exist).
  • The patient should be checked in (the appointment status should be “Checked In” or “Open”).
  • You need the Healthcare Practitioner or Nursing User role.

​
Opening the Visit Record

​
Easiest Way: From the Appointment

Open the Patient Appointment record and click Create Patient Encounter. This creates the visit record already linked to the patient, the appointment, and you as the practitioner.

​
From the List

  1. Go to Home Care workspace → Consultation section → Patient Encounter → New
  2. Link the patient manually
Patient Encounter form showing the patient name, date, practitioner, and tabbed sections for complaints, findings, diagnosis, medicines, and orders

​
Step 1: Check the Patient’s Background Before Starting

Before writing anything new, always look at the patient’s previous records:
  • What was the reason for the last visit?
  • What did the nurse find at that visit?
  • Are there any pending concerns or follow-up items?
  • Has the patient been taking their medicines?
  • Are there any new allergy alerts?
You can see all of this from the patient history (see Patient Management).

​
Step 2: Record What the Patient Is Reporting

In the Symptoms section, write down what the patient is telling you:
  • What is bothering them today?
  • Is it the same problem as last time or something new?
  • How bad is it on a scale of 1 to 10?
  • When did it start?
  • Is it getting better, worse, or staying the same?
Use the Symptom library to select common complaints (for example: wound pain, breathlessness, swelling, weakness, dizziness, nausea). You can also type in the patient’s exact words in the details field. Common home care patient complaints:

​
Step 3: Record What You Found

In the Examination section, write down what you observed and measured during the visit:
  • General appearance: Is the patient alert? Drowsy? In pain?
  • Skin: Is there any redness, rash, swelling, or breakdown?
  • Wound (if present): What does it look like today compared to last time? Is it healing?
  • Limbs: Any swelling? Can they move them?
  • Breathing: Is it easy or laboured?
  • Abdomen: Any tenderness or bloating?
  • Oral hygiene: Is the patient managing to clean their mouth?
  • Mental state: Are they oriented (do they know where they are and what day it is)?

​
Step 4: Record the Vital Signs

Vital signs are measurements that tell you how the patient’s body is working. Record them from the Vital Signs record linked to this visit: If any vital sign reading is outside the normal range, note it clearly in the visit record and inform the supervising doctor.

​
Step 5: Record the Diagnosis

After examining the patient, write down the diagnosis (the medical conclusion about what the problem is).
  1. Go to the Diagnosis section of the visit record
  2. Click Add Row
  3. Select the diagnosis from the library (e.g., Wound Infection, Hypertension, Urinary Tract Infection, Pressure Ulcer Stage 2, Generalised Weakness)
  4. If the patient has more than one problem, add a row for each one
If you are not sure of the diagnosis and the patient needs to see a doctor for clarification, note this in the examination section and book a doctor visit.

​
Step 6: Prescribe Medicines (If Needed)

If a medicine needs to be given or changed, the doctor records a prescription from within the visit record. See Medications and Pharmacy for full details.

​
Step 7: Order a Blood Test (If Needed)

If a blood test is needed, the doctor raises a Service Request from within the visit record:
  1. Go to the Service Requests / Orders section
  2. Click Add and select the test template (e.g., “Blood level test”)
  3. Save the visit record
A Lab Test record is created. A lab technician will be scheduled to collect the sample on a later visit. See Laboratory for the full process.

​
Step 8: Add Clinical Notes

Clinical Notes are free-text notes that do not fit neatly into any structured field. Use them for:
  • Communication to the next caregiver (e.g., “patient was very anxious today, took longer to settle before wound dressing”)
  • Instructions for the family member (e.g., “ensure patient sits out of bed for at least 2 hours each day”)
  • Observations about the home environment (e.g., “floor is slippery near bathroom, recommended non-slip mat”)
  • Response to previous treatment (e.g., “wound looks significantly better compared to last visit - less redness, no discharge”)
To add a clinical note:
  1. Go to Home Care workspace → Consultation section → Clinical Note → New
  2. Link to the patient and the visit
  3. Type your note

​
Step 9: Submitting the Visit Record

When everything has been documented:
  1. Click Submit in the Patient Encounter
  2. Confirm the submission
After submission:
  • The visit record becomes permanent (it can be amended but not freely edited)
  • It appears in the patient’s history timeline
  • The appointment status changes to Closed
  • The visit appears in the “Appointments to Bill” count if not yet invoiced
Important: Do not submit the record until everything for the visit has been entered. Submitting means the visit is officially over and complete.

​
Field Guide: Patient Encounter (Home Visit Record)

​
Best Practices

  • Always check the previous visit record before starting the new one - this keeps the care continuous and avoids repeating questions the patient has already answered
  • Write the examination notes as if the next person reading them has never met the patient - because they may not have; clear, specific notes like “wound on left calf, 3cm x 2cm, clean base, minimal discharge, healing well” are far more useful than “wound looks OK”
  • If you see anything concerning (a vital sign outside normal range, the patient seems confused, the wound looks infected), do not just note it and leave - contact the supervising doctor during or immediately after the visit
  • Submit the visit record on the same day as the visit. Records left in draft are incomplete patient documentation and will block billing.

​
Troubleshooting

The visit record is not showing in the patient’s history Check that the Patient Encounter has been submitted, not just saved. Only submitted records appear in the history timeline. I cannot find the right diagnosis in the diagnosis library If the diagnosis is not in the pre-set list, you can type it as free text in the visit notes until the administrator adds it to the Diagnosis library. The caregiver submitted the record but made a mistake A submitted record can be amended. Open the record and click Amend to make a correction. The original record is preserved and the amendment is tracked with a version history.