Version 21.0

Overview

Just like you can layer templates, you can layer previous data from a patient's chart into a note you're writing.  This can potentially save you a lot of time when charting on complex patients.  This article discusses how to quickly import pieces from previous encounter notes and/or messages into an encounter note.

Apply a Prior Encounter Note or Message to a Current Encounter

Select the Prior Encounter or Message to Import

1. From your current Encounter Note, in the CC/HPI/ROS tab, click the Prior Notes button.

1. You will be presented with the patient's Prior Encounter Notes and Messages window. Some tips for this screen:
   • Data shows in reverse chronological order.
   • You can opt to see all prior data or the most recent data from a lookback period you specify by using the radio buttons in the upper left.
   • You can identify the type of data shown based on the background color of the cells: 
     • Messages (including portal messages) have a pale yellow background.
     • Finalized Encounter Notes have a white background.
     • Currently open Encounter Notes, if any (including the note you're working on today, if you have saved it at least once) are bright yellow.

1. You can review the contents of an Encounter or a Message before applying it.
   • To review the contents of a particular encounter, highlight the encounter, then click View / Edit Note & Addenda. The Encounter Summary Sheet will appear:

     

   • To review the contents of a phone message (before actually applying it), simply hover your mouse over the phone message.  You can scroll down if needed:

1. Once you have found the message or encounter you wish to apply, highlight the encounter or phone message.
2. Then click Apply to Current Encounter.

Importing a Prior Encounter Note - What Should I Import?

You now have the opportunity to select pieces of the note you want to import. Sections which are greyed out indicate that these sections were not part of the prior encounter note, and thus there is nothing to import.   For example, this prior note had nothing in Review of Systems or Procedures, so those sections are greyed out.

1. Select the checkboxes for sections you want to import.
2. Click OK.
3. The selected original note components are overlaid across the existing note. 

Importing a Prior Encounter Note - How are prior note components overlaid?

CC and HPI 

• The CC and HPI will be inserted as a subsequent CC/HPI set, similar to adding an additional complaint. 
• Your original CC/HPI for this note, if you inserted them, will be present as the first CC/HPI set.

Review of Systems

• ROS questions are imported, along with color coding and Comments, only for ROS questions which are not yet answered in the new note.  "Not yet answered" refers to questions in either a Skip and N/A state.  
• PMFS History Meds Reviewed:  Contents of the PMFS History / Meds reviewed box are imported as-is from the prior note (including the time/date stamp).

Objective Exam

• Narrative:  Narrative exam notes will copy into each of the narrative exam components (e.g. General Appearance, EENTN, Lungs).  They will appear after the narrative exam notes that already exist in each section, if any.  This may cause duplication or potentially even contradiction.  Be sure to double check the results of an imported exam.  
• Detailed: Detailed exam notes, along with color coding and Comments, are imported only for exam notes which are not yet present in the new note.  "Not yet present" refers to exam details in either a Skip and N/A state.

Assessment

• This imports all the Diagnoses from the prior note, as well as the Assessment tab contents from the prior note.
• Both the Diagnoses and the Assessment will appear after any Diagnoses and Assessment already in your new note (if any).

Plan

• This imports the Plan from the prior note.
• The copied Plan appears after the Plan already in your new note (if any).

Procedures

• This imports any CPT codes (e.g. 99213) attached to the prior note and attaches them to this note.  
• It also imports any previous diagnoses attached to the prior CPT codes and adds them, under Assessment.
• Because coding should be individualized to the care you provided at each visit, apply a previous note's Procedures section cautiously!

Importing a Prior Message

If you apply a previous message, the entire contents of the message (including the metadata) appear in the Chief Complaint of the note: