INFO- Clinical EMR: Starting and Managing Visit Notes

For a PACE organization, there are many providers signing off on visit notes within the Clinical EMR.  The high volume of multiple providers (both prescribing and non-prescribing) may result in multiple drafts in the patient chart. 

Below, we outline our best practice recommendations for starting a Visit Note from Care Hub or within the clinical EMR, and how to identify whether a Visit Note is already in progress under another user. The goal is to prevent accidental deletion, overwriting, or signing of another team member’s note.

🎥 Video Walkthrough

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Key Steps

1. Start the Visit Note from the scheduled event in Care Hub 

• In Care Hub, open the patient’s scheduled event in the Agenda view
• Select the appointment time to open Event Details.
• Choose Start a Visit Note.
• This workflow immediately opens a new note and is the preferred method when you are the person initiating the documentation.

2. Use the open note to document and save as a draft if needed 

• Once the Visit Note opens, enter the required clinical information.
• If you are a nurse, medical assistant, or another supporting team member, complete your portion of the note.
• Save or close the note as a draft if documentation will be completed later.
• This approach supports a clean workflow when you are the intended note starter.

3. Check the requiring action queue when working inside the EMR 

• If you are already inside Alation/clinical EMR, go to the Requiring Action queue.
• Look specifically for Visit Notes that have been started.
• Identify whether the note is shown as:
  • Unsigned
  • In progress
• If the note is already signed, it will appear in the chronological record instead.

4. Respond correctly when the system detects an in-progress Visit Note 

• If you select Start a Visit Note from within the EMR and a note is already in progress, the system will prompt you.
• You will be asked whether you want to:
  • Open the existing in-progress note, or
  • Create a new Visit Note
• Review the prompt carefully before choosing an option.

5. Open the correct note and avoid deleting another user’s work 

• If you choose to open the in-progress note, the system will open the most recent draft.
• Be aware that this may belong to another user. 
• Do not discard the note unless you are certain it is yours.
• Discarding a note may delete another user’s documentation.

6. Safely exit if you do not need to work in the existing draft 

• If you do not want to continue in the open note, close it instead of discarding it.
• The safest option is to return to the practice home to close the note.
• Then re-enter the patient chart only when you are ready to document.

7. Verify note ownership before documenting in the patient chart 

• Before starting documentation, check the patient’s unsigned notes.
• Confirm which provider the note is listed under.
• Remember that the note is associated with the provider listed on the note, not necessarily the person who opened it.
• The note typically defaults to the patient’s primary care provider unless changed after opening.

8. Follow the safest documentation workflow 

• Best practice is to:
  • Start the Visit Note from Care Hub whenever possible.
  • Check Requiring Actions before opening or signing any note in the EMR.
  • Avoid opening or signing someone else’s draft.
• If possible, complete and sign your note in one session to reduce confusion.
• If you cannot finish, leave the note in draft rather than discarding it.

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Cautionary Notes

• Do not discard an in-progress Visit Note unless you are certain it is your own; discarding may delete another user’s work.
• Opening an in-progress note will usually open the most recent draft, which may belong to another provider.
• A note shown as unsigned/in progress is not yet finalized; a signed note will appear in the chronological record.
• The provider listed on the note may not be the person who started it, so always verify ownership before editing or signing.
• If you are unsure, close the note and return to practice home rather than taking action that could affect another user’s documentation.

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Tips for Efficiency

• Start Visit Notes from the scheduled event in Care Hub whenever possible for the cleanest workflow.
• Use the Requiring Action queue to quickly identify unsigned or in-progress notes.
• Before opening a note from the EMR, confirm the provider name to avoid working in the wrong chart entry.
• If you only need to review, close and re-enter the chart instead of discarding the note.
• When feasible, complete documentation and sign in a timely manner to reduce draft confusion. Each provider's draft notes can be found in their Practice Home queue.