EMR - Provider Documentation Workflow
Written by Niki Budd
Updated at June 25th, 2026
Table of Contents
Whether you're a new customer, onboarding new staff, or just need a refresher — this one's for you. We're often asked, "How should I document?" While you should always defer to your employer and state regulations, we do have a suggested flow to help ensure you document in the right place and build good habits from the start.
Use this as a quick-reference guide for documenting new injuries, follow-up visits, and referrals in Healthy Roster. Download and print the Provider Documentation Workflow reference card to keep at your desk.
General Recommendation based on Situation
Step 1 — Go to the Incident Report Tab
Start here for every new injury or problem. This is your entry point for all new documentation.
Step 2 — Select Add to Create an Incident Report
This is your provider-specific documentation — think of it as your SOAP note.
Step 3 — Add the Injury/Problem
Create the injury/problem directly within the incident report to save time. The injury/problem is the report of what's happening.
Step 4 — Continue Documentation
Answer background questions, add notes (use templates!), and associate any relevant attachments.
Step 5 — Select Save & Add Encounter/Treatment (Provider Only)
This carries the injury/problem over to the encounter. Encounters/Treatments are the services you, the provider, render to your patient/athlete.
Step 6 — Add Service Provided
Input the services rendered — AT Evaluation, tape, modalities, etc.
Step 7 — Select Save
You're done with today's services!
Step 8 — Referral/Follow-Up (if needed)
Instead of Save, select Save AND... Follow-Up/Referral. Referrals/Follow-Ups are services you're sending your athlete/patient out for — you are not the rendering provider.
When an athlete returns for follow-up care, skip the incident report and go straight to the existing injury.
Step 1 — Open the Injury
From the patient's injury tab, select the injury in question.
Step 2 — Review the Injury Timeline
Review the historical documentation for that injury before adding anything new.
Step 3 — Use Quick Add / View Timeline
From the timeline, you can quickly add: Encounter/Treatment, Status Update, or Referral/Follow-Up.
🔁 For subsequent days, repeat the Returning Visit Flow until the injury has resolved.