A Clinician can choose to either create a New Encounter or revise an Existing Encounter.

When creating a New Encounter, a window will appear (default setting), giving the Clinician the option to select an Encounter Template:

  • a Template that is linked to a Presenting Issue, or

  • Select from a Folder of Templates

The Clinician can also opt to select no templates by closing the window.

NOTE: Once an Encounter has been signed, it can only be edited by Unlocking the Encounter. (by a user with the appropriate user permissions)

There are various ways in which a Clinician can Create a New Encounter or Access an Existing Encounter.

An Encounter

Each Encounter is made up of numerous components to document various parts of a clinical visit.

Qnaires

  • Integrate Patient Reported Data collected via Qnaires directly into the Encounter Note. Attach an Answer Sheet to include responses that the patient has previously answered. By clicking on the title of the Qnaire, patient’s answers and the ability to edit the responses will be enabled. 

  • Clinicians can also complete a Qnaire during an encounter. 

  • Click on the Collect Data Button to choose which Qnaires are to be completed.

  • This will prompt up a column on the right side of the screen to access and view the Qnaires

History

  • The History Section is a dedicated space to record the clinical history associated with a given Encounter. 

  • Qnaires can be used to collect patient reported data on history and using the Natural Language function, this can be auto populated in the History, saving time during appointments.

Examination

  • The Examination Section enables clinicians to record objective information based on physical exam findings. Standard measurements, including vital signs, can be recorded in the fields provided.Further details can be recorded in the text box.

  • NOTE: Once the patient’s height and weight is entered; the BMI value will automatically be calculated.

Assessment and Plan

  • The Assessment and Plan Section enables clinicians to record all relevant diagnoses. The text box below gives space to record the clinical assessment and recommended treatment plans given to the patient.

  • To add a new diagnosis, Click "Add Diagnosis" to search the diagnostic code standards (selected in Template Settings). Search by numerical code or description.

Prescriptions

  • Create a prescription within an Encounter by clicking "Add Prescription"

  • Prescriptions can also be created outside an Encounter, in the Patient’s Chart under the Start/Open Menu --> Prescriptions. 

Attachments

  • Any File or Form associated with the patient (such as a PDF or image file) can be directly attached to the Encounter. The uploaded file will also be accessible in the Patient's Chart under the Start/Open Menu --> Patient Files tab.

Automated Follow-Up

  • Follow up Qnaires can be scheduled for a Patient to complete before their next visit through the Automated Follow-Up section of the encounter.

  • This can also be managed from the Scheduled Qnaires tab (under the Start/Open Menu), outside an encounter. 

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