Add a Nurse Visit Template

Version 14.8
Utilities > Manage Clinical Features > Encounter Template Editor

Overview

You will have an understanding of the content of a typical nurse visit template.  You will be instructed on how to add a template to ensure the templates reflect the workflow of the practice.

  1. Click the Utilities button  on the menu toolbar.

Menu Toolbar: Utilities

  1. Select Manage Clinical Features
  2. Select Encounter Template Editor. The template list displays.
  3. Click the plus to expand System: Nursing Visits.

Encounter Template Editor: Nursing Visits Templates


It is not required to expand the group, but it is good practice to make sure you do not duplicate a template.
  1. Click the Create a new template button .
  2. Add the template properties using the table definitions below.

Encounter Template Editor: Template Properties

Property
Description
Template
Name given to a template. Should be named for ease of searching.
Category
Method of organizing like templates. All templates edited in this section will be located in the Nurse Visits category.
Author
Assignment of a template to a specific user. Templates assigned an author may only be edited by that user.
Appt Type
Selection of a default appointment type. Not a requirement to save the template.
Visibility
Ability to restrict who can view the selected template. All symptom templates will have a visibility of Any staff member.
Location
Assignment can be made to view templates by location.
Finalize Status
Selection set to who may finalize. Most templates will be set to Providers only, but if the nurse staff have permission to finalize their notes the status would be set to Any Clinician.
  1. Click the Encounter Note tab  if not already selected.
  2. Enter a complaint into the CC field OR Click the Phrase Construction button  and insert phrases.

  1. Enter the history of the complaint into the HPI field OR Click the Phrase Construction button  and insert phrases.

  1. Complete the remaining fields of the Encounter Note tab.

 

Field
Description
Assessment (optional)
The likely diagnosis should be included in this section of the note. If a conclusive diagnosis has not been made yet, some possible diagnoses can be charted. It may include additional diagnoses that need to be ruled out.
Plan
This describes what will be done to treat the patient – ordering labs, referrals, procedures performed, medications prescribed, etc. This should address what was discussed or advised with the patient as well as timings for further review or follow-up are generally included.
Instructions
Instructions entered will be visible on the Patient Portal when the template is selected. Instructions are typically a summary of the visit written for understanding by the reader.
  1. Click the Detailed ROS tab .
  2. Set the ROS Questions/Symptoms.

Review of Systems may be optional for a Nurse Visit template.


Encounter Template Editor: ROS

Setting
Description
Pert
Relevant symptom/question to display when template is opened.
Reports
Positive for the symptom/question
Denies
Denies the symptom/question
N/A
Not applicable for the template. Removes from the group list.
  1. Click the Orders/Workflow tab.

This tab is optional. Only go to this tab if you need orders placed when the Nursing Visits template is used.
  1. Click the Procedures tab .

This tab is optional. Only go to this tab if you need procedure billing complete when the Nursing Visits template is used.