Create Encounter Note

Please note that this functionality is not available to all users at this time.  The functionality will be rolled out in phases.

The encounter note allows the provider to document the results of the patient’s visit.  The screen is broken into two sections which are referred to as the left-hand side and right-hand side of the chart. The left-hand side will display clinical data and is organized in tabs. The right-hand side is the encounter note.

To complete an encounter note:

Step 1: Click the Start Note button

Step 2: Select the appropriate note type

When the screen displays, it will be split into two areas.  The Patient Chart will be located on the left and Encounter Notes on the right. 

Step 3: Select the date of the encounter.  The default is today’s date.  The date can be modified but no future dates are available for selection.

Step 4: Select the facility where the patient was seen.  Default is the patient’s last facility in which they treated.  The facility can be modified by selecting from the dropdown.

NOTE: The will - minimize the encounter and the X will close the encounter. 

Step 5: Document the details of note

Step 6: Click Finalize

NOTE: The Finalize button will become enable after you scroll to the bottom of the ESRD/AKI Mgmt tab located on the left-hand side of the screen.

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