Mobile Limited and Comprehensive Encounter Note
Limited and Comprehensive Encounter notes are available to all providers. They can be accessed from the “Note” option in the right corner of the patient chart or the blue plus icon on the Dialysis Schedule.
After the "Note" option is selected, tap the appropriate encounter type.
Once the note is created, you will select the date of the encounter. The default is today's date. The date can be modified, but no dates before 90 days from today or future dates are available for selection. The patient's facility can be changed by clicking the X next to the facility name.
The time zone variance alert appears when you create a new Limited or Comprehensive encounter note, and the time zone for the patient’s home facility and encounter are mismatched.
The encounter note contains two statements and is divided into sections. The level of documentation detail is up to the provider’s discretion.
The "Encounter Completed With Telehealth" statement allows a provider to document that the encounter was completed with telehealth. The second statement, "Completed H&P," enables the provider to document if the patient's annual history and physical (H&P) were completed during the encounter. When available, the last completed H&P date will appear next to the "Completed H&P" statement. To mark a statement as true, tap the "Yes" radio button to the right of the statement. The button will turn blue when selected.
The note contains the same sections as the note on the OneView web version. The sections are collapsed by default. The note sections can be collapsed or expanded for added flexibility. The dash will collapse the section, and the plus will expand it. The dash/plus are located to the left of the section titles.
Fluid/BP, Adequacy, Access, Anemia, Nutrition, Mineral/Bone Disorder, Infection, and Other sections use a focused documentation approach, requiring notes when there are pertinent findings.
The note sections may contain a free text comment box, radio button selections, pre-defined responses, most recent lab values, and/or a "Reviewed" toggle. To select a radio button option under one of these areas, tap the appropriate radio button, and it will turn blue. To unselect the option, tap again to deactivate it.
A comments box may be available for optional additional details. When the copy forward feature is enabled in Setting > Customization (OneView web version), the comment from the most recent finalized note will automatically appear in the selected care categories with the provider and date of encounter for which the comment was copied. If there is no comment in the most recent note, then that care category comment field will be blank.
The copied-forward comment should be reviewed so that the wording accurately reflects and represents the care and observations for that specific patient visit. The copied comments can be edited or deleted by tapping the comment text box.
The most recent lab values and draw dates from the previous 6 months are shown in the appropriate sections. Click the "Reviewed" toggle next to the applicable section if applicable. The Reviewed toggle will automatically be enabled if pertinent lab values are addressed by tapping the radio buttons or notes are typed in the Comments box.
The note can be minimized or maximized at any time by tapping the blue banner that contains the note type and date. To minimize the note, tap the blue banner and then navigate to any part of the patient chart. To maximize the note, tap the blue banner, and the note is re-initiated.
Please be aware that the encounter notes automatically save all changes as soon as they are entered. The Finalize button will have the last saved time. Tap the Finalize button to complete the encounter.
Limited and Comprehensive Encounter notes created on mobile appear in the Provider Notes section of the Clinical Summary tab, Dialysis Schedule, In Progress Notes, and the Monthly Visit Summary report on the OneView web version.
Limited and Comprehensive Encounters can be edited or amended on Mobile. In the Clinical Summary section of the patient’s chart under Notes, a list of encounter notes for the past 90 days appear. Slide the Comprehensive Encounter to the left to reveal the Edit or Amend option.
Content on this site is for informational purposes only and does not represent actual patient data.