Encounter Note

      The Note button is available to create an encounter note.  The Note button is visible in all tabs under Patient Chart, and the functionality for this feature is the same under all the tabs.

      After selecting the Note button, choose a note type.  The options are Comprehensive Encounter, Limited Encounter, PD Encounter, HHD Encounter, AKI Encounter, Transition of Care, Home Training Encounter, and Non Billable.  The level of documentation detail is up to the provider’s discretion.  The note types have the same fields and basic functionality except for the following differences:

      • Comprehensive Encounter
        • Labs not for the treatment of ESRD is available, if applicable
      • PD Encounter and HHD Encounter
        • Telehealth hyperlink to DaVita Care Connect is available
        • Labs not for the treatment of ESRD is available, if applicable
      • AKI Encounter
        • Fluid/ BP – Achieving Target Weight field is removed
        • Fluid/ BP – Urine Output and Blood Pressure on Dialysis fields are added
        • Adequacy – spKdt/V field is removed
        • Adequacy – Creatinine Trend, eGFR > 15, and BUN Trend fields are added
        • Mineral/Bone Disorder - PTH-I is removed
        • Transplant Status – Section is removed for this note type
        • AKI Diagnosis – Contains the number of days treated as AKI patient and date, as well as, a comment text box
        • AKI Attestation (Displays on day 30, day 60, and day 90 that the patient has been treated as AKI.)
      • Transition of Care
        • Contains only hospitalization dates, post discharge follow up, and plan of care sections to document the transition of care process following a patient being discharged from the hospital
      • Home Training Encounter
        • Telehealth hyperlink to DaVita Care Connect is available
        • Contains only the Home Training section for documenting that a PD or HHD home training encounter was provided
      • Non Billable Note
        • Contains only the date of activity and note comment sections and is used to document a patient interaction that doesn’t result in a billable activity

      Once the note type and date are selected, the encounter note will display.  If issues arise with loading lab data, an error message will appear that describes the issue and workaround.  The encounter note contains two statements and is divided into sections.   The “Encounter Completed With Telehealth” statement allows a provider to document that the encounter was completed with telehealth.  The second statement, “Completed H&P”, allows the provider to document if the patient’s annual history and physical (H&P) was completed during the encounter.  The last completed H&P date will appear next to the “Completed H&P” statement when available.  To mark a statement as true, click the “Yes” pill button located to the right of the statement.  The pill will turn blue when selected.  

      For home encounter types (PD, HHD, and Home Training), a blue Telehealth hyperlink is available.  When clicked, the Telehealth link will take you directly to DaVita Care Connect (DCC) to allow you to complete a telehealth visit.  DCC will open in a new browser with you already logged in.

      To read more about H&P notes, click here.

      Details about each section are listed below:

      Patient Status, Access, Infection, Other, and AKI Status only have a free text box where data can be typed or dictated.  The box will expand as the text is entered. 

      History will pre-populate the patient's medical, surgical, social, and family history comment field’s latest history information.  The last updated date will display above the history information.  The information can be updated at any time.  Changes can also be made from the Clinical Summary tab of the patient’s chart.

      Physical Exam has 5 common nephrology-specific areas to document the physical exam of a patient.  To select an option under one of these areas, click the appropriate pill button  and it will turn blue.  To unselect the option, click again to deactivate it.  Beyond the pre-defined responses, the comments icon can be clicked to open the comment box to type additional context.  For Neck and Abdominal, the plus icon  reveals the hidden pill buttons.   Other pertinent findings can be documented at the bottom of the section in a comments box, as necessary.

      Fluid/BP, Adequacy, Access, Anemia, Nutrition, Mineral/Bone Disorder, Infection, and Other use a focused documentation approach which is the process of requiring notes when there are pertinent findings. 

      Each care category has a green “Scroll To” link in the header which quickly takes you to that data in the ESRD/AKI Mgmt section on the left-hand side for reference purposes.  The most recent lab values and draw dates from the previous 6 months are shown in the appropriate sections.  If applicable, click the “Reviewed” toggle next to the applicable section.  The Reviewed toggle will automatically be enabled, if pertinent lab values are addressed by clicking the pill buttons or notes are typed in the Comments box.  A message displays underneath each “Reviewed” toggle that clarifies the document by exception intent of the note.  When the “Reviewed” toggle is on, additional information will be under the note header stating, “Clinical assessment at goal unless otherwise documented.”

      Each care category will contain the finalized encounter note comments from the past 90 days.  These comments can be copied into the care category comments field. 

      Assessment & Plan will have a read-only text box where comments entered into each care category (except for Patient Status and Physical Exam) will automatically be displayed. Clicking on any of the blue care category titles will redirect you back to that section in the encounter note in case further edits are required.  

      “COPY INTO NOTE” functionality should only be used when the included wording accurately reflects and represents the care and observations from that specific patient visit and should not be inserted into any patient record without careful review.  All copied text must be thoroughly evaluated for appropriateness to the specific encounter.

      NOTE: The care category comments are from finalized encounter notes created in OneView.  Comments in an unfinalized OneView encounter note or a Falcon Silver encounter note will not be displayed.

      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.  When you start a Limited Encounter note, the Overall Patient Status and Fluid/BP sections will be expanded and all other sections will be collapsed.  For all other note types, all sections will be expanded. 

      Click " COPY INTO NOTE" to pull the comment information from the selected finalized note.  After the comment is copied, it include the information of provider and date of encounter for which the comment was copied. 

      The comment can be modified.  The “Copied from” information will disappear when any modification is made to the copied comment.

      The ability to document medical necessity for labs designated as not for the treatment of ESRD is available through the encounter note for labs classified under Nutrition, Infection, or Other.  Non-ESRD lab results that were entered through CWOW and Snappy in the last 90 days will display.  This functionality is available in the Comprehensive, PD, and HHD encounter note types. 

      Select either “ Changed Care Plan” or “No Change” and document comments, if necessary.  A “Past Due” indicator will display if the lab has not been reviewed within 30 days of the resulted date.  Entering documentation for a non-ESRD lab through the encounter note will remove that lab from the Labs Not For ESRD Treatment queue and vice versa.

      Transplant Status contains fields to document if the patient is a transplant candidate, any free text transplant comments, the patient’s transplant status, and status date.  Once the transplant status data is documented, the most recent transplant status data will pre-populate in the encounter note and display on all PDFs that are created in OneView.  The most recent transplant status will not be added to the PDF for Silver encounter notes.

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