Patient Encounter: Summary

OP sets all defaults to share all information. Any individual decisions by Practice-users to restrict information sharing (access, use, or exchange) are the responsibility of the Practice in the implementation of its 21st Century Cures Act Information Blocking policies and procedures for its Practice and patients.

Version 20.18

This window map article points out some of the important aspects of the window you're working with in OP but is not intended to be instructional. To learn about topics related to using this window, see the Related Articles section at the bottom of this page.

About Patient Encounter: Summary

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

The Encounter Summary allows you to review and finalize an Encounter Note. It displays the details entered in the previous sections of the Note. 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 accesses the Summary window in the patient's Encounter Note.
2
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.
3
Function buttonsThe Function buttons delete an entire Encounter Note, edit an Encounter Note, or save an Encounter Note.
4
Summary Report CriteriaThe Summary Report Criteria selects created Report Criteria in a drop-down menu. 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 the Rebuild Summary button.
6
Flag as Incomplete checkboxThe Flag as Incomplete checkbox marks an Encounter as unfinished.
7
Print buttonsNotes and Letters are printed using the Print Note and Print Letter buttons.
8
CDA buttonThe CDA button will create a CDA for the selected Encounter.
9
Search barThe Search bar is used to locate specific content in the summary.
10
Clinical Note Type

The Clinical Note Type drop-down list allows practices to select the type of clinical note they are charting. The options are:  

  • Progress Note (default while in an Encounter Note) 
  • Consultation Note
  • History & Physical
  • Procedure Note
  • Imaging Narrative
  • Discharge Summary Note
11
Note VisibilityThe Note Visibility drop-down menu determines who can view the Encounter Note.   
12
Save Template buttonThe Save Template button saves any changes to the template and closes the summary sheet.
13
Finalize and Cosign buttons
  • Finalize: Approves and locks the patient's Encounter note. Once the note has been finalized, it cannot be changed. After a note has been finalized, additional information can be added in the Addenda tab The user finalizing the note is displayed in the Finalized by field.
  • Cosign: Adds a cosigner to the patient's Encounter Note after a note has been finalized. The logged-in user who cosigns the note is displayed in the Cosigned by field.
Version 20.17

About Patient Encounter: Summary

Path: Clinical, Practice Management, or 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 drop-down menu. 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 drop-down menu 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 buttonThe Save Template button saves any changes to the template and closes the summary sheet.