EHR documentation
Keep notes clear, objective, and EHR-ready for care continuity and reporting.
Documentation pattern
- Use objective language and exact timestamps.
- Include what was observed, what was done, and patient response.
- Record escalation events and callback outcomes.
- Review entries before export to ensure record completeness.
Example
14:20: Patient reported shortness of breath when standing. SpO2 93%. Assisted to seated position. Recheck at 14:35 SpO2 96%. Family contact notified.
Exporting documentation reports
When your notes are finalized, use the Reports workspace on the Home tab to generate and export the current report summary output for handoff or provider review.