🎓 eLearning course:Encounters (providers)

The encounter section of the chart allows you to do the most common tasks you'll do to track patient interactions. This includes recording notes, prescribing medications, writing letters, creating bills, and more. From the encounters section, you can easily view all the providers interactions with a specific patient, see Viewing all encounters for a patient.

Encounter Templates

If you routinely see the same condition and create similar encounter notes, you can use an encounter template. For more information, see Creating encounter templates and Using encounter templates.

Starting an encounter

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

Customizing the encounter

Click a section header to minimize that section when it's not in use. If you never use a specific section, you can remove it completely. For this and other user specific customizations, see Customizing your encounter settings.

Saving and signing

The CHR auto-saves within 10 seconds of every change you make. But, you can save at any time. Just click Save. If you are using dictation software, you must first click into the field you want the text to populate and press a key to trigger the autosave. If instead, you sign the encounter, this locks the contents so they cannot be altered without unlocking. For more information, see Signing encounters.

Encounter header

The header of the encounter contains the following:

Item

Description

Back

Return to the encounter section.

Visit Date

If the encounter was started from the schedule or visits dashboard, the appointment date is automatically filled in.

Click to choose from a list of the patient's appointments or select a date manually.

Contributors

Shows which users worked on the encounter.

Click Add My Review to manually record that you have contributed or signed off on the encounter. Your name along with the date and time is added.

Accessibility

Specify what users can access the encounter. For more information, see Restricting access to specific encounter notes.

Template

Add an Encounter Template after the encounter is created (see Using encounter templates).

Letter

After the encounter is signed, click Letter to create a signed letter. For more information, see Creating letters from encounters.

PDF

Create a PDF copy of the encounter to print, email or fax. For more information, see Generating a PDF of an encounter.

Delete

If the encounter is not signed, click to delete. If the encounter is signed, you will need to unlock first before you can delete. For more information, see Deleting an Encounter (Draft or Signed).

Unlock

Once an encounter note is signed (see Signing encounters), it is locked and cannot be modified. A user with appropriate permission is able to unlock the encounter (see Unlocking a signed encounter).

Presenting Issue

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

It can pre-populate from an Encounter Template or the Presenting Issue from a linked appointment.

Click to search from a list of your presenting issues, or save custom text.

For more information on how to add a presenting issue, see Recording encounter notes.

Created on

Date the encounter was created,

often the same as Visit Date but is a separate data point.

Encounter Body

The body of each Encounter is made up of numerous sections to document various parts of a clinical visit. The main Encounter note (progress/consultation note), comprises the History, Examination and Assessment and Plan sections. For more information on the actions available for each section, see Recording encounter notes.

Section

Description

Qnaires

Include patient reported data collected via Qnaires.

For more information, see Attaching Qnaire responses to encounters.

History

A dedicated space to record the clinical history associated with the encounter.

Examination

Record objective information based on physical exam findings.

Standard measurements, including vital signs, are recorded in the available fields (see Recording patient vitals and measurements in encounters).

Assessment and Plan

Record the clinical assessment and recommended treatment plans given to the patient.

A new diagnosis can also be added. These diagnosis codes can automatically be added to billing or the patient's Medical History. For more information, see Syncing diagnosis codes.

Prescriptions

You can easily create new prescriptions from within the encounter. For more information, see Quickly adding a prescription during an encounter.

Attachments

Include a file or form associated with the patient (such as a PDF or image file). For more information, see Adding attachments to encounters and Adding forms to encounters.

📌 Note: The uploaded item is saved to the patient chart.

Referrals

Include information from your encounter note in a letter. For more information, see Creating letters from encounters.

Or start a referral with your encounter note attached, see Creating internal referrals and Creating external referrals.

Injections

Record patient immunizations or other types of injections. For more information, see Recording immunizations and injections.

Automated Follow-Up

Schedule follow-up Qnaires for a patient to complete before their next visit. For more information, see Setting up scheduled or follow-up Qnaires.

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:

Updated November 4, 2022

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