Documentation · 3 min
Start with the source
Separate a documented fact from a reasonable-sounding assumption.
Read once for the encounter
Before you write, read the full synthetic encounter. Identify who is speaking, what they report, and what the source explicitly confirms. A plausible detail is still an unsupported detail.
Keep uncertainty visible
If a dose, date, or other detail is missing, preserve that uncertainty. In this prototype, use “not supplied” or a clarification flag rather than filling the gap from memory.
Review the note against the source
Compare each statement with the encounter. Ask whether a reviewer could trace it back to a source fact. The demonstration rubric helps structure this comparison; it does not validate real patient documentation.