Provider: Chart a Sick Visit (Encounter)

Version 14.8


This section will introduce the users to the steps required to complete an Encounter visit.  The user will be guided through the windows of an encounter (sick visit) with steps to easily finish the visit.  This section is specific to the provider workflow.

  1. From the Patient Tracking window, highlight the patient.
  2. Click the Chart button located on the toolbar.
  3.  Confirm window displays for the Problem List.

  1. Click the OK button or Cancel button.
  2.  Confirm window displays for the patient medication allergies.  

  1. Click the OK button or Cancel button.
  2.  Confirm window displays for the patient medication.

  1. Click the OK button or Cancel button.
  2. The Patient Chart window displays.
  3. Click the Encounters button, located on the left panel of the chart.

  1. All Encounters documented for the patient display, the current encounter will be at the top of the list.
  2. Click the Open Note button.
  3. Click the Summary button to review the current documentation. You can set this tab to always open on Summary.

Note: The note summary may display when opening the note if the provider used the Pref feature button to always open an encounter on the Summary.

  1. Select any or all of the below areas to review, modify or add information.
  1. Click the Detail Exam button.
  2. Select the template to apply by clicking the drop-down arrow at the top of the window. 

Begin typing the name of the template.

  1. The Apply Template dialog box displays, click OK to apply the template sections. You can choose to remove certain sections by removing a check mark.

  2. Enter abnormal findings and additional comments.
  3. Click the Assess/Plan button.
  4. Click the Coding button.
  5. Verify the correct ICD10 code(s) are selected.
  6. Click Use Suggested CPT.
      Click the selected code from the Superbill and click on Use button or you may double click on the selected code.

  1. Click the Summary button and review.
  2. Click the Finalize button.
  3. Confirm window displays, click the OK button to finalize - or - Cancel button to return to the Summary window.

  1. Click the drop-down arrow at the Visit Status column and change to MD: Finished.

Note: The Visit Status list may be different at each practice.  Select the appropriate status to indicate the provider has finished with the patient.