After consent, you land on the visit hub — the patient's name with the visit's documentation sections. Work through them in any order. Everything saves on your phone as you enter it.
Section | What you do there | Appears |
Vitals | Enter or verify measurements | Most visits |
Medications | Review and reconcile the list — see Add and verify medications | Most visits |
Wounds | Document each active wound, or record none | Most visits |
Procedures | Record care performed, or mark none | Most visits |
Visit Schedule | Enter the visit frequency | Start-of-care visits |
Orders | View and create provider orders | When your agency enables it |
PT / OT / ST Eval | Discipline evaluation sections | Therapy visits |
Watch the Outline
The Outline badge in the top-right corner is a checklist of required documentation for this visit type, shown as a percentage. Tap it to see what remains. It highlights red or amber until the critical sections are complete.
Enter vitals
Tap Vitals.
Enter what you measured: pulse (apical or radial), temperature, respiration, height, weight, blood pressure (left or right), pain assessment, and oxygen saturation. Leave a field blank if it was not measured.
Tap Done. The hub shows a check on Vitals.
Warning: Scribe may pre-fill values from the recording. Verify every value against your own assessment before tapping Done. If a transcribed value is wrong, correct it by hand.
Document wounds
Tap Wounds.
Document each active wound — location, measurements, tissue type, drainage, and photos when your policy requires them. Mark no wounds if that is accurate for the visit.
Note: A patient with an active wound on file that you do not address blocks submission later. Document or acknowledge it here rather than at review.
Record procedures
Tap Procedures.
Record the care tasks performed — wound care steps, IV management, or whatever your agency configures. Mark No procedures when that is accurate.
Enter a visit frequency (start of care)
On SOC-type visits, tap Visit Schedule.
Enter the 60-day frequency string — for example
2WK2means two visits per week for two weeks. Separate segments with commas:2WK2, 1WK4.Save when the field validates.
Red error text means the format or episode dates are wrong — fix it before saving. Amber warnings mean the frequency may exceed the episode; adjust it or confirm with your clinical manager.
If something goes wrong
A section you expect is missing. Sections follow the visit type, and some (Orders, therapy evals) depend on your organization's setup. Tell your scheduler which visit and which section.
The Outline percentage will not move. Tap the badge and work the named items. A section counts once it is marked done, not merely opened.
No signal. Nothing changes. Documentation saves to the phone and sends when you reconnect.