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Chart an Encounter with a Well Visit

Version 14.19

Overview

While charting a Well Visit, the provider may find that he/she needs to incorporate an Encounter Visit note for the same day. The steps below instruct on how to chart an Encounter from within an open Well Visit Note.

Add an Encounter Note While Charting a Well Visit

  1. Save the work you have already completed in the Well Visit by clicking the Save button.
  2. Click Plan/Orders.
  3. Click the Add Sick Encounter button. This opens an Encounter Note.
  4. Click CC/HPI/ROS and enter the below information, if applicable.
  • CC: Enter the patient's complaint. Optionally you may include "See Well Visit for Exam Findings".
  • HPI: Document the history of the complaint.
  • ROS: Select relevant findings.

Note: If your practice uses symptom templates and an appropriate one exists, you may apply one by searching for and selecting the template in the All templates drop-down.

  1. (Optional) Click Detail Exam, and using the All templates drop-down, select a diagnosis template.
  2. Click Assessment and confirm the diagnosis code.
  3. Click Plan/Orders to review the patient plan and add tasks such as medications, labs, referrals, or follow-up.
  4. Click Coding, review the suggested E/M code and click the Use Suggested button or select the appropriate code(s) using the code categories.
  5. Click Summary and review, click the Finalize button if the note is complete. Otherwise, click Save to return to the Well Visit Note.
  6. Proceed with coding and finalizing the Well Visit Note.

Notes:

  • The diagnosis code for the Well Visit note is automatically updated to the code with abnormal findings.
  • When reviewing the patient chart there will be two notes for the same date of service, a Well Visit Note and an Encounter.
Version 14.10

Overview

While conducting a Well Visit, the provider may find that he/she needs to incorporate a Sick Visit Encounter note for the same day. From within the Well Visit:

  1. Save the work you have already completed in the Well Visit by clicking the Post Edit button .
  2. Click the Assess/Plan tab.
  3. Click the New Encounter button . This will open a new Encounter Note.
  4. Click the CC/HPI/ROS tab if you're not already there.
Note: If your practice uses symptom templates and an appropriate one exists, you may apply one now by searching for and selecting the template in the All templates dropdown. Then, you can proceed to click the Assess/Plan tab indicated in step 8 and go from there.  If not, the process to the next step.
  1. In the CC, enter the patient's chief complaint and add "(See Well Visit for Exam Findings)".
  2. Enter the HPI (since this is not available in the Well Visit).
  3. Document any ROS findings.
  4. Click the Assess/Plan tab within the Encounter Note.
  5. Using the All templates dropdown, select a Diagnosis Template.
  6. Confirm the diagnosis code is appropriate to your findings.
  7. Complete the Orders worksheet (if needed) to create orders for any tasks such as medications, labs, referrals, or follow-ups.
  8. Click the Coding tab.
  9. Review the suggested E/M code and click the Use Suggested button or select the appropriate code(s) using the code categories.
  10. Click the Summary tab.
  11. Review and finalize the Encounter note. You will be returned to the Well Visit Note.
  • The diagnosis code for the Well Visit is automatically updated to reflect "with abnormal findings".
  1. Proceed with coding and finalizing the Well Visit note.
Note: When reviewing the Chart for the patient, you will now see two visits for the same date of service: the well visit in the Well Visits tab and the sick visit in the Encounters tab.