Every encounter note will automatically have an encounter type of Office visit selected, though you can adjust the type as needed. This is the basic categorization of what type of visit occurred, e.g. office visit, nurse only, or home visit.
Only Office visit, Home visit, Nursing Home visit, and Telemedicine visit will count toward Meaningful Use and clinical quality measures calculations.
Chief complaint and vitals
These fields can be completed by any user with an Edit Level of Nurse or higher.
Create and submit lab and image orders electronically directly from an encounter for a more holistic view of the patient visit. Orders that have been associated with a chart (either by ordering from the encounter or selecting an encounter note within the order) will display in the Orders section with the associated status (e.g. draft, submitted, received). If the order is saved as a draft, you can click on the draft to complete the ordering workflow.
Screenings, assessments, and interventions are events which took place during the patient encounter, such as preventive screenings, referrals, or additional diagnostic tests. Learn more >>
Some items recorded here are shared with patients through their personal health record (PHR). See the complete list.
Observations are free text fields which are used to record functional and cognitive status of the patient. If applicable, you may also check the No impairment box. This information is not shared with the patient through PHR.
Quality of care
Quality of care data is used to record additional actions taken during the encounter. These items also feed into specific clinical quality measures (CQMs) and Meaningful Use measures. This information is not shared with the patient through PHR.
Simply record your care plans and instructions in the Care Plan section of the note, and the notes in that section will automatically be available to patients in their personal health records (PHR) once you sign the note. Learn more >>