Navigating An Encounter

This page will explain how to navigate an Encounter, breaking down each tab, button, and screen.

Encounter.png

Navigating the Encounter Window

Encounters are broken down into a series of Tabs across the top of the encounter. These tabs are:

  • Visit Note — The primary tab for charting the note. This will be the primary focus area for the physician charting the note.
  • Diagnosis — This screen will list all current visit diagnoses and patient diagnoses for this particular patient and encounter, as well as your SmartSheet10 quick lists.
  • Invoice — This screen is where the Invoice of the encounter is located. To cover Creating Claims in more depth, please refer to our Billing portion of this guide.
  • All Documents — This will show all previous encounters created for the patient.

Note: The encounter window can be minimized to allow the user access to that patient's chart for the review of medical information.

Visit Note Tab

This tab will serve as the primary screen for the Encounter. Tailored toward charting the note, this screen is broken down into various fields and options.

From the top of the screen, the date and provider are set under the Date and Provider drop-down menus. The Facility where this service was rendered will also be selected from a drop-down menu on this screen.

  • Quick Links — The “Quick Links” drop-down menu will allow you to complete various fields of your encounter without the need for scrolling through the body of the encounter to click on each individual field. Please note that only those fields that have been entered into the template of the encounter will be usable. For example, if you have an ROS field, rather than scrolling down in the encounter to access the ROS field, you can click on this drop-down menu to select ROS, make all necessary selections, and Save to enter this ROS information to the body of the encounter.
  • Refresh — The Refresh button will refresh the encounter to reflect any recent changes.
  • Rx — This button will allow you to write a prescription from inside of the patient’s encounter.
  • Scan — This button will allow you to scan an image as an attachment, using your default scanner settings.
  • Webcam — This button will allow you to capture a webcam image as an attachment.
  • Attachments — This button will allow you to attach images to an encounter.
  • Meaningful Use — This checkbox will determine whether or not this visit will count as part of your meaningful use totals. This should be checked for all encounters that are created to document a face-to-face encounter with a patient.
  • Edit/Format/View/Insert/Table — These tabs will allow for customization of the chart note, functioning in a similar fashion to any word processing software.
  • Print/Print Preview — These buttons will allow you to print or print preview the visit note.
  • Font, Font Size, Font Formatting — These options may all be selected in the upper portion of the Visit Note screen. These will function identical to any word processing software.
  • Undo — This selection will allow you to undo your most recent change to the encounter.
  • Hotspots — This drop-down menu will allow you to insert a hotspot image into the body of the chart note. This will allow you to “click where it hurts” on the presented image. The verbiage behind these selections will populate into the chart note, and an image of the selections made on the foot will attach to the encounter.
  • Print View — This will put the chart note into Print Layout display.
  • Tab Blanks — Checking this box will allow you to use the “tab” key on your keyboard to move through the blank fields in your note. Any item that is indicated as a __ will open when using the tab blanks feature.
  • Show Fields — Checking this box will highlight all data fields in yellow.

Adding Additional Fields

When charting the note, additional data fields and mini-templates may be added by utilizing the menu on the right-hand portion of the encounter window. There are four tabs to navigate in this window: Templates, Patient Data, Text Fields, and Custom Fields.

Additional Options

  • There are several other options and features located in the upper-right hand portion of the Encounter screen that you will utilize:
  • Tasks — This button will allow you to record a new message task for the patient.
  • Alerts — This button will allow you to view the patient's alerts.
  • Go to Patient Chart — This button will minimize the encounter and show the patient's chart.
  • Close — This button will close the encounter without saving.
  • Save & Close — This button will save the encounter, then close.
  • Sign & Close — This button will sign the encounter, marking it as completed, then close the encounter.

Actions

There are several additional actions that may be completed from inside of the encounter after charting has been finished:

  • Ref. Letter — This will allow you to send a referral letter from inside of the encounter.
  • Patient Forms — This option will allow you to create a patient form for this encounter.
  • Print — This will allow you to print the chart note.
  • Edit Document Template — This will allow you to edit the template selected from inside of the encounter for future use.
  • Save as New Document Template — This will allow you to save the edited template as a copy, rather than overwrite the pre-existing template.
  • Export CCDA — This will allow you to generate a CCDA for the patient from the patient’s encounter.
  • Scan — This will allow you to scan an image as an attachment, using your default scanner settings.
  • Webcam — This will allow you to capture a webcam image as an attachment.

Templates

The Templates tab will allow you to select from a list of mini-templates to insert into the chart note. Utilizing this tab will allow you to insert an additional Subjective, Objective, Assessment or Plan to the note regardless of the template you originally selected.

Checking the box labeled Edit Mode will allow you to edit each mini-template from this screen. Once you have checked the Edit Mode box, simply click on “Edit” next to the mini-template to open the template editor.

Mini-templates are sorted by category on default and can be browsed by selecting from the drop-down menu “Select a Template Type.”

Once a template has been decided, place your cursor into the chart note in the exact location you would like to insert the mini-template, and click “Select” next to the name of the template in the mini-template list. This will insert the template into the chart note, where you can now make any necessary choices.

Patient Data

The Patient Data tab will allow you to insert patient information directly into the chart note based on where your cursor is currently placed. There are several categories of patient data.

  • Patient Fields — These fields are used to populate relevant information to that patient such as Age, DOB, and Name.
  • Patient Data — These fields will pull over medical information pertinent to the patient, such as Patient History, Lab Results, Active Medications and Allergies, and Primary Diagnosis.
  • Visit Fields — These fields will allow you to populate visit specific information in the note, such as ROS, HPI, and more visit specific fields such as Visit Date, Problems, or Provider.
  • Misc. — These fields contain any information that is not patient or visit specific, such as Practice information and UserName fields.
  • Billing — These fields include billing related information such as Marital Status, Legal Representative, and Monthly Due Date.

Text Fields

Text Fields are neutral data fields which may be inserted into the chart note. For example, Yes-No choices, Pos-Neg choices, Number entry fields, and Option fields. These are best utilized for creating a dynamic chart that may be modified and answered quickly. With Text Fields, you may also generate multiple choice selections or single choice selections.

Answering Data Fields

Data fields will be indicated in the encounter as yellow highlights which may be clicked on to make the necessary selections. Data fields that do not show as highlighted in yellow can be highlighted by clicking the “Show Fields” checkbox.

To answer these data fields, simply left-click on each field and answer the question that will pop up in a separate window on the encounter. These data fields can be customized when creating the encounter. More details can be found in the Importing a Template and Converting a Template portions of this guide.

Data fields can be seamlessly navigated by checking the box titled “Tab Blanks,” which will allow you to use the Tab key on your keyboard to move through each hyperlink.

Custom Fields

The Custom Fields tab will allow you to create a preloaded multiple choice field that you can then select quickly to insert into various templates throughout your database. To add a new custom field, click the Manage Fields button under the Custom Fields tab, then click Add Field. This will open a window to name the custom field. After naming, click the Add/Edit Values button to add your possible answer, separated by a comma and a space.

After adding your values, click OK. Click Save to save this custom field.

To then insert this custom field into a template, place your cursor where you would like to insert this custom field and click the desired field out of the list of fields under Custom Fields.

Completing the Note

After a note has been completed, you will need to electronically sign the note. To do so, click the “Sign & Close” button in the upper right-hand corner of the screen.

If you are not completed with the note but need to close the encounter window, simply click “Save & Close” so you may return to the note later to finish.

“Close” will close the encounter screen without saving or signing the note. Ensure you have saved all necessary changes to the encounter before selecting this option.

As A Measure of Meaningful Use

Creating an Electronic Note is a part of Meaningful Use Stage 2, specifically Menu Set Objective 2. It is an optional measure, but is one recommended by TRAKnet, due to its ease of use and the high chance it is already being completed.

Stage 2 Information
Objective Record electronic notes in patient records.
Measure Enter at least one electronic progress note created, edited and signed by an EP for more than 30 percent of unique patients with at least one office visit during the EHR Measure reporting period. The text of the electronic note must be text searchable and may contain drawings and other content.
Exclusion Any EP who has no office visits during the EHR reporting period.

Click here for the CMS website guide on this measure.

Additional Material

Related Pages

Creating an Encounter
Template Creation Quicksheet
Managing Templates

Unless otherwise stated, the content of this page is licensed under Creative Commons Attribution-NonCommercial-NoDerivs 3.0 License