Description
Screen where the encounter information is completed and the progress note is closed. Also on this screen, the type of visit is identified for billing purposes. (The information regarding diagnostics and procedures that will be displayed on this screen, will be the same as the one displayed in the billing area.)
Access
Through Main Menu
- Click on the Clinical button, in main menu.
- Select the patient from any section of the Clinical Records screen.
- Once you have completed the clinical evaluation, click on the Save button, located at the top of the screen.
Sections
Buttons
- Add Dx: Allows you to add diagnostics, to the Todays Dx section.
- F Codes: Allows to add the F codes to the Encounter Procedures section, which apply according to diagnoses, vital records, among others.
- HEDIS F Codes: Allows you to add the F codes, which apply from HEDIS.
- Signatures: Allows to register the patient's signature, the signature of a relative or legal guardian, in case of being a minor patient, to be displayed in the progress note.
- Patient Signature: Allows to register the patient's signature.
- Parent or tutor signature: Allows to register the relative or legal guardian signature.
- Frequent Procedures: Allows to add frequent provider procedures, previously configured.
- Note: Frequent codes are configured in the Settings / General / Staff & Providers, selecting the provider and pressing the button called Close Encounter Code Settings.
- Add Procedures: Allows to add more procedures performed in the encounter.
- Leave Note Open: Allows to leave open the progress note.
- Save and Close: Allows to save and close the progress note. (Recommended.)
- Note: Once the progress note is closed, it cannot be modified. Only one Addendum/Amendments, will be allowed.
- Previous: Closes the screen.
Sections
- Billable Problem List: In this section, the diagnoses to be billed for the encounter will be displayed.
- Todays Dxs: In this section, the diagnoses added in the clinical evaluation of the current encounter, will be displayed.
- Patient Current Diagnosis: In this section, the patient's active diagnoses are displayed.
: Allows to copy the diagnostics from the Patient Current Diagnosis section, to the Encounter Billable Problem List section, to be used in the billing section.- Meaningful Use Summary Settings: This section is used to upload various Meaningful Use measurements.
- Auto-upload clinical summary for this patient: When you select and save the closed progress note, the clinical summary, will be sent to the patient portal.
- Note: To achieve this, you need to register the "Direct" email from the patient portal on the "Patient Details" screen.
- Print Clinical Summary (PDF): When selecting and saving the closed progress note, the Clinical Summary, will be displayed to be delivered to the patient.
- Direct: The patent's portal address will be displayed, which is registered in the Patient Details screen.
- Email: The registered patient's email will be displayed, on the Patient Details screen.
- Auto-upload clinical summary for this patient: When you select and save the closed progress note, the clinical summary, will be sent to the patient portal.
- Encounter Procedures: In this section, the selected procedures codes that apply to the encounter, will be displayed. Use Default Codes, select this checkbox, if you want to use the codes by Default, previously configured.
- Assessment / Plan: In this section, both, the Assessment and the Plan, which was built on the Advanced Progress Note screen, will be displayed.
- Use Default Codes: Selecting this option, will display the default closing codes.
- New Visit: Display the office codes, pressing them, will be copied to the Encounter Procedures section. The user will be able to configure the codes to be displayed in this section.
- Note: In order for user preference codes to be displayed in this section, they will be configured in Settings / Clinical / Closing Procedures Settings.