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 Start Note button is available to create an encounter note.  Start 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 Start Note button, chose a note type.  The options are Comprehensive Encounter, Limited Encounter, PD Encounter, HHD Encounter, and AKI Encounter.  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 and Limited Encounter
    • Telehealth option added in response to CMS lifting site restrictions on telehealth services due to COVID-19
  • PD Encounter
    • Telehealth hyperlink to DaVita Care Connect is available
  • AKI Encounter
    • AKI Status – Section to enter AKI comments
    • 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

Once the note type and date are selected, the encounter note will display.  The encounter note is divided into sections.  Details about each section are listed below:

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

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 " Go 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.  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. 

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. 

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 to 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.

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.

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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