Clinical: Start a Sick Visit (Encounter)
In this section you will find the steps for opening an Encounter from the Tracking Window.
Provider: Chart a Sick Visit (Encounter)
This section will introduce the users to the steps required to complete an Encounter visit.
Apply a Template to the Note
This section deals with message/prompts when opening a note, parts of an Encounter note, and the Visit Info section of the note.
Document Chief Complaint-History of Present Illness-Review Of Systems
This section will introduce the users to the section of the Encounter note used to document the chief complaint, history of present illness and the review of systems.
Medications Administered in the Office
Version 14.19 Overview This article demonstrates best practice when administering medications at the practice. You will see instruction for three scenarios: When a Provider is responsible for writing the prescription. When the N...
This section will introduce the users to the section of the Encounter note used to document or review history.
Past Medical History (Encounter)
This section will introduce the users to the section of the visit note used to document or review past medical history.
When a new appointment is made, the front desk staff will select the Appointment Type (Symptom template). The nursing staff will apply the Symptom template when they open the note.
Allergies and Reactions (Encounters)
In this section, you will find the steps to review and document the patient's medication, non-medication and/or vaccine allergies/reactions.
Family Medical History (Encounter)
This section will introduce the users to the section of the Encounter note used to document or review family medical history.
Social History (Encounter)
This section will introduce the users to the section of the visit note used to document or review social history.
Document the Physical Exam (Detailed)
This section will introduce the users to the section of the Encounter note used to document the exam. The user will be guided through the form to add or modify information.
Manage the Order Worksheet
The Order Worksheet is used to assign tasks to departments within the practice.
Order Worksheet: Lab Tab
This section of template design demonstrates the edit or addition of diagnostic tests associated to a template.
Order Worksheet: Patient Education Tab
This section will introduce the users to the steps to add Patient Education Resources to Encounters during a visit.
Order Worksheet: Follow Up Tab
This section describes how follow up visits are created by tasks. From the Patient Encounter or Preventive Exam click on the Assess/Plan tab, click the F/U tab.
Order Worksheet: Other Tab
How to add other tasks from the Assess/Plan section of a note.
Order and Procedure Templates
Order and procedure templates are generally applied from the Assess/Plan tab to create orders, add procedures and add coding to the visit. These templates may need to be built for your practice.
Code and Finalize an Encounter Visit (Sick Visit)
This section will introduce the users to the steps required to code a visit and finalize the note.
Finalize Open Encounters (Sick Visits)
This section will go over how to complete notes that have not been finalized within the encounter with a patient. The user will be shown optional settings to ensure all notes are addressed.
Create an Addenda
After a note has been finalized, an addenda can be created and viewed under the Addenda tab.
Encounter Visit (Sick Visit ) Placeholder
In this section you will find instruction on how to create a sick visit placeholder.
Set a Default Exam Template
A default sick visit is helpful for providers who like to chart while in the room with the patient.
Diagnosis and Plan Templates
DIAGNOSIS template titles are written in all capital letters. If the template is applied from the Detailed Exam tab, this will affect what information is populated.
Newborn History (Encounters)
Version 14.19 Overview This section will introduce users to the section of the visit note that is used to document or review newborn history. The user will be guided through the fields to easily review and document additional information. Add o...