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Documenting Patient Encounters

Once a patient has been checked in, the next step is to create an encounter. An encounter is the digital chart for a specific visit, containing all the clinical notes, vitals, diagnoses, and billing information related to that appointment.

Creating an Encounter

The encounter is automatically created when you check a patient in. The best practice is to open the encounter from the patient's dashboard.

  1. Check the Patient In: From the main calendar view, click on the appointment time, change the Status to Arrived, and click Save.

  2. Go to the Patient's Dashboard: Open the patient's chart. You can do this by clicking the patient's name in the calendar pop-up or by using the Patient Finder.

  3. Open the Encounter: Once you are on the patient's dashboard, look for a dropdown menu just below the main header. This menu lists the patient's past and current appointments. Select the encounter for today's visit from this list.

  4. You will be taken to the patient's encounter screen for the current visit.

Key Components of an Encounter

The encounter screen is organized into a menu of forms on the left that allow you to document the visit. These forms are nested under expandable sub-menus.

  • Clinical Notes (SOAP): Found under the "Clinical" sub-menu, this is where you document the visit using the Subjective, Objective, Assessment, and Plan (SOAP) format.

  • Vitals: Also under the "Clinical" sub-menu, this form is used to record the patient's vital signs, such as height, weight, and blood pressure.

  • Fee Sheet: Found under the "Administrative" sub-menu, this is where you will add the CPT and ICD-10 codes for the services and diagnoses related to the visit. This information is used for billing.

Navigating the Encounter

The encounter menu on the left is organized into expandable sub-menus, such as 'Clinical' or 'Administrative'. To open a form, first click on a sub-menu to see the available forms, then click on the specific form you need, like 'Vitals'.

Each form will open in its own tab at the top of the encounter, allowing you to easily switch between the summary, vitals, clinical notes, and other sections without losing your place.