The encounter note is organized in sections including (but not limited to) patient status, history and physical, physical exam, fluid/BP, labs, and assessment and plan.
|
The note sections can be collapsed or expanded for added flexibility.
Most encounter notes have all sections expanded by default.
The only exception is the Limited encounter - the Overall Patient Status and Fluid/BP sections will be expanded and all other sections will be collapsed. |
Sections in the Encounter
|
|
History
The History section will pre-populate the patient's medical, surgical, social, and family history comment field’s latest history information.
| Slide the H&P toggle to indicate that a History and Physical was completed. |
| The date the history information was last updated will display above the history information. |
The information can be updated at any time in an encounter note. Changes can also be made from the Clinical Summary section of the patient’s chart.
Physical Exam
| The 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. Click it 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. |
Labs Not for the Treatment of ESRD
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 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
|
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 created in OneView.
Assessment & Plan
Assessment & Plan is a read-only section that will have a copy of the comments entered into each care category (except for Patient Status and Physical Exam).
|
Clicking any of the blue care category titles will redirect you back to that section in the encounter note in case further edits are required. |
All Orders
|
The All Orders section of an encounter note allows providers to review their unsigned orders for a specific patient while rounding. |
This feature provides a consistent order review and signing cadence that promotes patient safety.
For more information, reference this article.
Focused Documentation Approach
|
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. |
For more information, reference this article.
Content on this site is for informational purposes only and does not represent actual patient data.