1The core question
Everything Welnote does answers one question: how does a patient receive support through Welnote? Not how data is stored—how a real person moves from a community visit to the right level of care and back again.
2How care moves
A case can travel along a chain of people, each adding what only they can, without the patient having to repeat their story or travel to find the next link.
Patient
→ Community health worker (structured intake, follow-up)
→ Nurse (local clinical judgment)
→ Doctor (asynchronous review, care plan)
→ Specialist (remote review for complex cases)
→ Program manager (oversight, continuity, reporting)
The chain is not always linear, and most cases never reach a specialist. The point is that the path exists and the record travels along it—so escalation and follow-up are deliberate, not lost.
3Community-based care
Care begins where the patient is. Community health workers—often the only health presence a family regularly sees—capture structured observations during home and community visits, even with no connectivity. They are the origin of truth in the system and the relationship that makes follow-up possible.
Field workers collect data, classify urgency with simple rules, and escalate. They do not diagnose or prescribe; that boundary is what keeps the model safe (see Clinical Safety & Scope).
4Referral workflows
A referral is a coordination event, not a slip of paper. When a case needs a clinician's judgment, it carries the relevant history with it so the reviewer inherits context, not just a name.
Field worker flags a case for review
→ Case enters a review queue
→ Doctor claims and reviews the patient timeline
→ Care plan and recommendation flow back to the field
For urgent danger signs, the pathway is different and explicit: immediate escalation toward in-person or emergency care, because Welnote supports escalation, not intervention.
5Follow-up workflows
Follow-up is where most fragmented systems fail, so it is a first-class concept here. A recommended follow-up creates an obligation that is scheduled, visible, and owned—then closed when the revisit happens.
Follow-up scheduled
→ Field revisit and updated observations
→ Outcome recorded
→ Re-enter the cycle if continued monitoring is needed
6Care pathways
The same coordination machinery supports several longitudinal pathways. Each is a sequence of structured observations and follow-ups over time, not a one-off encounter.
6.1 Chronic disease monitoring
Hypertension, diabetes, and asthma need repeated measurement and adherence support. Welnote keeps those episodes in one longitudinal view instead of scattering them across providers.
6.2 Maternal health pathways
Antenatal and postpartum care span months. Risk flags and visit history carry forward through delivery and beyond, and sensitive cases can be routed to women clinicians.
6.3 Child health pathways
Growth monitoring, nutrition, and infection screening rely on tracking change over time—a single weight means little; a trend means everything.
7Key message
Welnote is not primarily a record system. Welnote is a coordination system. The record exists so that care can move between people—reliably, accountably, and over time.