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Overview

Visit documentation allows providers to record clinical encounters, observations, assessments, and care plans for each patient visit. Complete and timely documentation ensures continuity of care and meets compliance requirements.
Documentation Timing: Best practice is to complete visit documentation within 24 hours of the patient encounter.

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Accessing Visit Documentation

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From Your Schedule

1

Open Your Calendar

Navigate to Schedule or Calendar
2

Select the Visit

Click on the scheduled or completed visit
3

Click Document Visit

Click Document Visit or Add Documentation

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From Patient Chart

1

Open Patient Chart

Navigate to the patient’s chart
2

Go to Visits

Click on the Visits tab
3

Select Visit

Find the visit to document and click Document or Edit

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Visit Documentation Components

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Chief Complaint

Document the primary reason for the visit:
FieldDescription
Chief ComplaintPatient’s main concern in their own words
DurationHow long the issue has been present
OnsetWhen symptoms began
SeverityCurrent severity level
Use the patient’s own words when documenting the chief complaint. This provides context and helps with continuity of care.

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History of Present Illness (HPI)

Document the details of the current condition:

Location

Where is the problem?

Quality

What does it feel like?

Severity

How severe is it (1-10)?

Duration

How long has it lasted?

Timing

When does it occur?

Context

What makes it better/worse?

Modifying Factors

What has been tried?

Associated Signs

Related symptoms?

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Review of Systems (ROS)

Systematic review by body system:
SystemCommon Items
ConstitutionalFever, fatigue, weight changes
HEENTVision, hearing, throat
CardiovascularChest pain, palpitations, edema
RespiratoryCough, shortness of breath
GIAppetite, nausea, bowel changes
GUUrinary symptoms
MusculoskeletalJoint pain, weakness
NeurologicalHeadache, dizziness, numbness
PsychiatricMood, sleep, anxiety
SkinRashes, wounds, lesions

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Physical Examination

Document your examination findings:
1

Vital Signs

Record or verify vital signs:
  • Blood pressure
  • Heart rate
  • Respiratory rate
  • Temperature
  • Oxygen saturation
  • Weight
2

General Appearance

Note patient’s overall condition:
  • Alert and oriented status
  • Level of distress
  • Mobility status
3

System-Specific Exam

Document relevant physical exam findings:
  • Normal findings
  • Abnormal findings
  • Changes from previous exam

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Assessment

Document your clinical assessment:
ComponentDescription
DiagnosesActive diagnoses addressed during visit
ICD-10 CodesAssociated diagnosis codes
Problem StatusImproved, stable, worsening
Clinical ImpressionYour professional assessment

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Plan

Document the care plan:

Medications

  • New prescriptions
  • Medication changes
  • Discontinuations
  • Refills

Orders

  • Lab orders
  • Imaging orders
  • Referrals
  • DME orders

Patient Education

  • Conditions discussed
  • Instructions given
  • Materials provided

Follow-up

  • Next visit timing
  • Monitoring plan
  • Return precautions

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Documentation Templates

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Available Templates

AllCare provides templates for common visit types:
TemplateUse For
Routine VisitRegular scheduled visits
Follow-upFollow-up from previous issues
Initial VisitFirst visit with new patient
Urgent VisitAcute concerns
Annual WellnessComprehensive annual exam
Medication ReviewMedication reconciliation

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Using Templates

1

Select Template

Choose appropriate template for visit type
2

Auto-Population

Template pre-fills common fields:
  • Patient demographics
  • Current medications
  • Active diagnoses
  • Previous vitals
3

Complete Documentation

Fill in visit-specific information
4

Customize as Needed

Add or remove sections as appropriate

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Completing Documentation

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Required Fields

Before saving, ensure these are complete:

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Signing the Note

1

Review Documentation

Read through the complete note for accuracy
2

Make Corrections

Fix any errors or omissions
3

Sign Note

Click Sign or Sign and Lock
4

Confirm

Confirm your electronic signature
Signed notes are locked. After signing, notes cannot be edited. If corrections are needed, you must add an addendum.

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Addendums

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When to Add an Addendum

  • Correcting errors in a signed note
  • Adding information received after signing
  • Clarifying documentation
  • Responding to queries

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Creating an Addendum

1

Open Signed Note

Navigate to the completed visit note
2

Click Add Addendum

Click Add Addendum button
3

Enter Addendum

Document the additional or corrected information
4

Sign Addendum

Sign the addendum (timestamp automatically recorded)

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Best Practices

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Documentation Quality

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Timeliness

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Compliance

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Troubleshooting

Possible causes:
  • Visit not yet on schedule
  • Wrong date selected
  • Different facility selected
Solution: Check the calendar date and facility. If visit is missing, contact AllCare Operations to add it.
Possible causes:
  • Required fields missing
  • Network connectivity issue
  • Session timeout
Solution: Check for validation errors (usually highlighted in red). Save frequently to avoid data loss.
Solution: Signed notes cannot be edited. Add an addendum with corrections:
  1. Open the signed note
  2. Click “Add Addendum”
  3. Document the correction or addition
  4. Sign the addendum
Possible causes:
  • Recent updates not synced
  • Viewing cached data
Solution: Refresh the page and verify current information. Recent changes from the facility may take a sync cycle to appear.

Clinical Notes

View clinical note history

Patient Charts

Access patient information

Visit Calendar

View your schedule

Patient History

Review patient timeline