Utilities > Manage Clinical Features > Encounter Template Editor
This article will help to provide you with an understanding of the content for a typical diagnosis template. You will be instructed on methods of customization to ensure the diagnosis templates reflect the workflow of the practice.
- Click Utilities in the main menu.
- Select Manage Clinical Features.
- Select Encounter Template Editor. The template list displays.
- Click the plus to expand System group.
- Double-click to open a template and click the Edit button.
- Review the template properties.
|Template||Name given to a template. Should be named for ease of searching. Diagnosis template titles are written in all capital letters.|
|Category||Method of organizing like templates.|
|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 Diagnosis templates should have a visibility of at least Provider.|
|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.|
- Click the Encounter Note tab if not already selected.
- Review and edit the fields of the Encounter Note tab.
|Counseling (optional)||Information entered includes counseling that is commonly done during the visit.|
|Coordination of care (optional)||Information entered includes activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health care services. Typically the information in this field is entered at time of visit.|
|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.|
- (Optional) Add a diagnosis code.
- Click the Add button .
|Note: Click the Prim? checkbox when the diagnosis code involves laterality, severity, etc., you can add multiple Primary Diagnosis codes that will create a pop-up when the template is applied to select the most specific code for that visit.|
- Click into the ICD10 Description field and click the Search button. The ICD10 search window displays.
- Enter a description or code in the ICD10 Code/Description field and select the diagnosis code.
- Click into the SNOMED Description field, begin typing and click the Search button. Select the SNOMED code.
- Click the Save button.
- Click the Detailed Exam tab and review or change the exam points using the table definitions below.
|Pert||Relevant symptom/question to display when template is opened.|
|ABNL||Positive for the finding|
|NL||Negative for the finding|
|N/A||Not applicable for the template. Removes from the group list.|
|Note: To expand an exam group, click the heading. Select the checkbox Show all groups to see additional Exam groups.|
- Click the Orders/Workflow Tab. Click here for detailed information on each tab in Orders/Workflow.
- Click the Procedures tab. Click here for detailed information on completing the Procedures tab.
- Click the Save Changes to template button .