Document an Encounter

This guide provides instructions for providers create, document, write notes, and sign off on patient encounters.

Create a new encounter

There are many ways to trigger and document a new patient encounter.

Option: From an apopintment on the patient chart

1. The Patient Chart Summary page displays upcoming appointments.
2. Click on Document Encounter to be directed to the Document encounter workspace.

Option: Ad hoc encounter

1. Open the patient’s chart and go to the Encounters table.
2. Select Add Encounter.
3. Fill in baseic encounter information such as:
   • Visit type: Select the visit type (e.g., Established Patient, New Patient, Follow-up).
   • Reason for Visit: Enter the reason for visit.
   • Rendering Provider: Select the rendering provider.
   • Supervising Provider: Select the supervising provider, if applicable.
   • Facility: Select the location where the visit took place.
   • Sensitivity: Set access restrictions if applicable (e.g., Normal, High).
   • Visit Date/Time: Defaults to current date/time.
4. Click Create encounter.

Document an encounter

1. In the Document Encounter workspace, begin documentating the encounter in the note section.
2. There are many ways to streamline documentation. For example:
   • Review previous encounter notes
   • Copy forward documentation from previous notes
   • Insert a note template
   • Use macros and dot phrases for documentation shortcuts
3. After completing note documentation, Sign & lock the note to prevent further changes.

Macros

Macros are keyboard documentation shortcuts. Macros may fall into different categories:

• Formatting - Impacts the format of the text, e.g. Heading 1
• Insert data - Inserts documented data from the patient chart, e.g. medications
• Add new data - Add a descrete data in the note, e.g. a new diagnosis. Once the note is saved, the information is stored to the patient chart, reducing the need to manually add it later.
• Launch workflow - Initiate a workflow such as ordering diagnostics labs or eRx.

To initiate a macro, type / (forward slash). Continue typing the name of the macro filter or use the arrow keys to select the macro and insert into the note.

Formatting

Macro	Description
Paragraph	Body text
Heading 1	Highest level heading format for main sections
Bullet list	Unordered, bulleted list
Numbered list	Ordered, numbered list

Inserting and add data

Macro	Description
Add diagnosis	Insert an active diagnosis from the problem list or add a new diagnosis
Add allergy	Add a new allergy
Insert allergy history	Insert active allergies from the patient chart. If no active allergies, then “No active allergies on file” wil be inserted
Add medication	Add a new medication statement
Insert medication history	Insert active medication statements from the patient chart. If no active meds, then No active medications on file will be inserted
Add vitals	Add new vitals

These macros will insert a “chip” of the respective clinical information. One chip per record. For example if you insert 5 diagnosis from the problem list, each diagnosis is displayed as their own chip. Clicking on the chip will launch the modal to edit the information. Delete the chip to remove the documentation from the note. Removing the chip from the note will not remove it from the patient chart.

If you create a new record or update an existing one using the macro, the record will automatically be updated to the patient chart. For example, if you add a new diagnosis in the note, the diagnosis will automatically show up in the problem list, which saves users from having to remember to document it again.

Any records added via macro will also be automatically link to the encounter, which you can see in the record itself. For example, to see which diagnoses where referenced in an encounter, go to the Problem List, expand “Additional Information” to see the section “Linked encounters”. This section will list all linked encounters with a hyperlink to jump to the encounter.

Launch workflow

Macro	Description
Launch eRx	Launch eRx modal. Click Back to note to close the window and return to the note. Available only when eRx is enabled