Patient Encounter: Summary

Version 14.19

About Patient Encounter: Summary

Path: Clinical tab > Patient Chart button > Encounter > New or Open Note button > Summary
Path: Practice Management tab > Patient Chart button > Encounter > New or Open Note button > Summary
Path: Billing tab > Patient Chart button > Encounter > New or Open Note button > Summary

The Patient Encounter helps to code and complete an encounter visit.  The encounter note encompasses both narrative and comprehensive formats. It also allows you to customize the layout of the note.  The note is added to the patient chart.

The Encounter Summary Sheet allows you to review finalized encounter notes.  The notes appears with all the details entered in the previous Encounter windows.  You can view the Primary Encounter Note and Patient Exit Note as they were created.

Patient Encounter: Summary Map

Number

SectionDescription
1
Summary buttonThe Summary button opens the Summary window in the patient's encounter note.
2
Encounter Function buttonsThe Function buttons delete an entire encounter note, edit an encounter note, or save an encounter note.
3
Flag as Incomplete checkboxThe Flag as Incomplete checkbox will mark an encounter as unfinished.
4
Summary Report CriteriaThe Summary Report Criteria selects created Report Criteria in a dropdown list.  Clicking the Edit Criteria button opens the Report Criteria window, where you can create or edit a criteria set.
5
Rebuild SummaryIf you would like to Rebuild the Summary for the Alternate Notes tab, select the Summary Report Criteria using the drop down arrow in the Summary Report Criteria and then click Rebuild Summary button.
6
Print buttonsNotes and Letters are printed using the Print Note and Print Letter buttons.
7
CDA buttonThe CDA button will create a CDA for the selected encounter.
8
Search barThe Search bar is used to locate specific content in the summary.
9
Notes
  • The Primary Encounter note tab displays the details of the primary encounter note including patient demographics, visit information (date, time and location), chief complaint, history of present illness, ROS findings, medications reviewed, etc.
  • The Patient Exit Note tab displays all the details entered into the patient exit note.
  • The Alternate Notes tab contains any alternate notes that may have been added to the encounter.
10
Note VisibilityThe Note Visability dropdown determines who can view the encounter note.   
11
Finalize buttonThe Finalize button approves and locks a patient encounter note.  Once the note has been finalized it cannot be changed.  After a note has been finalized, open the finalized note and click the Addenda tab.  An addendum can be created, edited, and viewed in the Addenda tab to add information to the encounter note. The user approving the finalized note will appear in the Note Finalized by field.
12
Cosign buttonThe Cosign button adds a cosigner to the patient encounter note after a note has been finalized.  The logged in user name clicking the Cosign button will appear in the Note Cosigned by field.
13
Save Template button
The Save Template button saves any changes to the template and closes the summary sheet.
Version 14.10

About Patient Encounter: Summary

Path: Smart Toolbar > Chart button > Encounters tab > Open Note > Summary tab
Path: Smart Toolbar > Schedule Button > Encounters tab >  Edit button > Summary tab

The Patient Encounter helps to code and complete an encounter visit.  The encounter note encompasses both narrative and comprehensive formats. It also allows you to customize the layout of the note.  The note is added to the patient chart.

The Encounter Summary Sheet allows you to review finalized encounter notes.  The notes appears with all the details entered in the previous Encounter tabs.  You can view the Primary Encounter Note and Patient Exit Note as they were created.

Patient Encounter: Summary Map

Number

SectionDescription
1
Encounter Note Editor tabs

The Patient Encounter Note Editor contains the following tabs:

2
Care Plans tabThe Care Plans tab lists, prints, and manages care plans for a patient’s health maintenance schedule.
3
Visit DateThe Visit date field indicates the date that the patient encounter occured.
4
Prior Notes tabThe Prior Notes tab lists the previous encounter notes and messages.
5
Templates tab

The Templates tab lists the templates that are created, edited, and reviewed in the Encounter Templates Editor. Templates are pre-written scenarios you can use in an encounter to document common pediatric diagnoses. Templates include detailed descriptions for the usual pertinent positive and negative findings of a wide variety of illnesses, with a standard assessment, plan and ICD-10 coding. Included with your installation of Office Practicum are Pediatric specific templates.

6

Summary Report CriteriaThe Summary Report Criteria selects created Report Criteria in a dropdown list.  Clicking the Edit Criteria button opens the Report Criteria window, where you can create or edit a criteria set.

7

Rebuild SummaryIf you would like to Rebuild the Summary for the Alternate Notes tab, select the Summary Report Criteria using the drop down arrow in the Summary Report Criteria and then click Rebuild Summary button.

8

Print buttonsNotes and Letters are printed using the Print Note and Print Letter buttons.
9
Search barThe Search bar is used to locate specific content in the summary.

10

CDA buttonThe CDA button will create a CDA for the selected encounter.
11
Notes
  • The Primary Encounter note tab displays the details of the primary encounter note including patient demographics, visit information (date, time and location), chief complaint, history of present illness, ROS findings, medications reviewed, etc.
  • The Patient Exit Note tab displays all the details entered into the patient exit note.
  • The Alternate Notes tab contains any alternate notes that may have been added to the encounter.
12
Note VisibilityThe Note Visability dropdown determines who can view the encounter note.   

13

Finalize buttonThe Finalize button approves and locks a patient encounter note.  Once the note has been finalized it cannot be changed.  After a note has been finalized, open the finalized note and click the Addenda tab.  An addendum can be created, edited, and viewed in the Addenda tab to add information to the encounter note. The user approving the finalized note will appear in the Note Finalized by field.

14

Cosign buttonThe Cosign button adds a cosigner to the patient encounter note after a note has been finalized.  The logged in user name clicking the Cosign button will appear in the Note Cosigned by field.

15

Save Template buttonThe Save Template button saves any changes to the template and closes the summary sheet.