Create Encounter Note
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 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 dates before 90 days from today or 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 were 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: View the patient’s lab results in the ESRD/AKI Mgmt tab before finalizing the encounter. Click the “Stroll To” link in the header to quickly go to that data in the ESRD/AKI Mgmt section.