Chart an Encounter with a Well Visit

Version 20.10

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 Assess/Plan and confirm the diagnosis code, Assessment and Plan.
  3. Click Orders to review the patient tasks such as medications, labs, referrals, or follow-up.
  4. Click Coding, review the suggested E/M codes. Select the appropriate code by clicking the Use Suggested button from Tracked Time or MDM. In addition, you may select the Categories or Templates radio button and choose additional code(s) .
  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 20.8

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.