Visits and notes

A visit is the clinical record of one encounter with a patient: the reason, the note, vitals, files, and follow-up. Open Visits (/visits) to see today's open visits and recently signed ones.

Start a visit

• From an appointment: open it from the calendar or queue and choose Start visit.
• From the worklist: choose Open visit on a waiting patient.
• Without an appointment: choose New walk-in visit, pick the patient, add the reason, and choose Create and start.

A visit moves through Waiting, In progress, In review, and Signed. It can also be Cancelled with a reason.

The visit workspace

The workspace keeps everything for the encounter on one screen:

• Patient: allergies, medications, conditions, active prescriptions, and previous signed visits.
• Pre-visit information: the patient's pre-visit brief when they completed a form.
• Clinical note: Subjective, Objective, Assessment, and Plan.
• Vitals and observations: blood pressure, heart rate, temperature, SpO₂, weight, height, glucose, pain score, and more.
• Transcript: dictation you type or paste, and the visit scribe when it is turned on.
• Attachments: images and documents for this visit.
• Follow-up: instructions for the patient and follow-up actions such as a lab test, imaging, referral, or the next appointment.

The note saves as you type. If someone else changes the visit at the same time, Wareed stops and asks you to reload instead of overwriting their work.

Drafts from the transcript

Choose Draft note from transcript to get suggested text for each note section. Drafts are suggestions only. Use Add to note for the ones you want and Discard for the rest. Nothing enters the note without you.

Review and sign

1. Choose Send for review when the note is ready, or sign directly if your role allows it.
2. Read the attestation. The default is I personally examined the patient and this note is accurate.
3. Choose Sign and lock.

Signing locks the note. Any approved scribe documents, such as a referral letter or patient summary, are saved with the signed record. Afterwards you can still Mark appointment completed if the appointment is open.

Corrections after signing

A signed note cannot be edited. Use Add addendum to add a dated correction or extra information under your name. The original stays as it was.

Change history

Every visit has a Change history: when it was created, each note edit, signature, observation, file, draft, addendum, and follow-up change, and who made it.