🎞️ View video tutorial: Starting encounters and recording encounter notes

An encounter is divided into sections where clinicians document various aspects of a clinical visit. A new encounter can start pre-populated with information from different sources, including:

  • data entered by frontline staff if they add presenting issues or an appointment type when creating an appointment

  • information provided directly by the patient through a Qnaire

  • variables (blue bubbles) if you selected a template

Notes are typically entered in the History, Examination, and Assessment and Plan sections of an encounter.

Steps

1. Start or access an encounter from your schedule, from the Visits dashboard, or from the patient's chart. See Starting an encounter.

2. If the patient has completed a Qnaire that contains natural language, a message similar to the following appears.

If you don't want to add the content, choose None from the Attach Paragraph to menu. Otherwise, select an option to add that content to the Bottom or Top of the History, Examination or Assessment and Plan section.

3. To enter a presenting issue, click the Unspecified issue text, or to change the presenting issue, click it. A list opens. You can choose from your most commonly used issues, or enter search text to find something more applicable. See Presenting issues for details.

4. If your encounter is populated from a template, instant variables (pink bubbles) may populate the History, Examination, and Assessment and plan fields. Click the instant variables as prompts to populate specific data.

Depending on how an instant variable is configured, clicking it may add content or present a list to choose from.

5. Enter or edit text in the History, Examination, and/or Assessment and Plan fields.

💡 Tip: Use the formatting tools in the bottom right corner of the field to enhance the text with bold, italics, and strike-through, and to add links and tables.

6. In addition to text, you can record standard measurements, including vital signs, in the Examination section.

Click + Add Vitals to add a standard Vitals row. See Record patient vitals and measurements in encounters for more information.

7. To add a diagnosis, in the Assessment and Plan section, click + Add Diagnosis to search by a numerical code or description. For more information, see Recording an encounter diagnosis.

💡 Tip: These diagnosis codes can automatically be added to bills associated with the encounter (see Encounter settings).

📌 Note: The CHR auto-saves within 10 seconds of every change you make. But, you can save at any time. Just click Save. If instead you sign the encounter, this locks the contents so they cannot be altered without unlocking.

Now that you've got notes in your encounter, here are some other things you can do:

Updated June 6, 2022

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