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 service facility location.
   • 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 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 / (backslash). 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