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Charting a Sick Visit with a Well Visit

Version 14.19

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.
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.