🎞️ View video tutorial: Starting encounters and recording encounter notes

An encounter is divided into sections where providers document various aspects of a clinical visit, such as prescriptions or a referral. For more information, see Overview of Encounters.

The main encounter note (progress note) comprises the History, Examination and Assessment and Plan sections.

A new encounter note can start pre-populated with information from different sources, including:

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, in the Attach Paragraph to list, choose None.

  • To add the content, in the Attach Paragraph to list, select History, Examination or Assessment and Plan.

    • Click to add the content to the Bottom or Top.

  • Click Attach.

3. To enter a presenting issue, beside Presenting Issue, click the Unspecified issue, and a list of your configured presenting issues opens. To add a new one, see Creating presenting issues.

  • Select a presenting issue from the list. If the presenting issue has a template associated with it, the template opens.

  • Or type a custom reason.

    • Click Save Custom Text.

💡 Tips:

  • To change the presenting issue, click it.

  • The presenting issue shows in the main Encounters section in the Concern column and is used to easily identify the encounter.

  • A letter generated from the encounter uses the presenting issue as the Letter Title.

  • A Referral generated from the encounter uses the presenting issue as the Reason For Referral.

4. If your encounter is populated from a template (see Starting an encounter), the configured text, variables, attachments etc. populate your encounter. For more information see Using encounter templates, Using instant variables and Using data variables.

5. Record your encounter, use the table below for reference.

Section

Description

Qnaires

Click Attach a Qnaire Response to include a previously recorded answer sheet. Or to complete a Qnaire during an encounter, click +Collect Data.

To view an answer sheet, click the Qnaire name, and the answer sheet opens in a new tab.

For more information, see <(xxx)>

History

Type to record the clinical history associated with the visit.

If required, complete any Patient Data Variables or Instant Variables. For more information see, Using instant variables and Using data variables.

Examination

Type to record objective information based on physical exam findings.

If required, complete any Patient Data Variables or Instant Variables. For more information see, Using instant variables and Using data variables.

To record standard measurements, including vital signs, click +Add Vitals. For more information, see Recording patient vitals and measurements in encounters.

Assessment and Plan

Type to record the clinical assessment and recommended treatment plans given to the patient.

If required, complete any Patient Data Variables or Instant Variables. For more information see, Using instant variables and Using data variables.

To add a new diagnosis, click Add Diagnosis. For more information, see Recording an encounter diagnosis.

Prescriptions

To create a new prescription, click Add Prescription. Or quickly choose medications from your favourites or the patients existing medications, or add a single medications. For more information, see Quickly adding a prescription during an encounter.

Once the prescription is added, click the feather icon to sign it, and either the print, download or fax icons to send the prescription.

To delete the prescription, click the trash can icon before it's signed.

Attachments

To attach a file or form associated with the patient (such as a PDF or image file), click +Add Form or +Add Attachment. For more information, see Adding attachments to encounters and Adding forms to encounters.

💡 Tip: The uploaded item is saved to the patient chart.

Referrals

To include information from your encounter note in a letter, click + Add Letter. For more information, see Creating letters from encounters.

To start a referral with your encounter note attached, click +Add Referral. For more information, see Creating internal referrals and Creating external referrals.

📌 Note: Once the encounter is signed, if a letter is generated, it is automatically signed by the provider.

Injections

To record patient immunizations or other types of injections, click +Add Injection. For more information, see Recording immunizations and injections.

Automated Follow-Up

To schedule follow-up Qnaires you want the patient to complete before their next visit, click + Add Follow-Up Qnaire. For more information, see Setting up scheduled or follow-up Qnaires.

To delete the Qnaire, click the trash can icon.

Billing Items

Include private, third party or provincial billing items in the encounter note to automatically pick up information such as the Service Date or Diagnosis code.

Creating provincial bills changes based on the province you are billing in. For more information, check out our province-specific help articles:

💡 Tips:

  • To add a link to a website, type the URL and press enter.

  • Format your text with the formatting tools.

    • Bold, italics, strike-though, underline.

    • Tables.

    • Text indents and text alignment.

    • Bullet points. (To stop the bullet points, click the bullet icon again.)

Updated October 13, 2022

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