The visit is recorded with consent and transcribed, and the draft note is waiting before the patient reaches the parking lot.
Where it happens
The visit, in auro EHR. This lesson is part of the Charting and the care plan track.
What this lesson covers
Step 1
Take consent, per visit
Recording is on or off before the visit starts, and the choice is stamped on the record.
Step 2
Have the visit
In the room or on Zoom. Nobody types, and nobody writes it up afterwards from memory.
Step 3
Read what the draft was made from
The transcript sits beside the note, so any sentence in the draft can be traced to something that was actually said.
Step 4
Edit, then sign
A draft is a draft until a clinician signs it. Signing is its own lesson, in Getting started.
After this lesson
You can run a recorded visit and say where any line of the draft came from.
The Academy keeps a record of what each person has completed. It is a record, not a credential: auro accredits no one, and no lesson carries CE or CEU credit.
