Description
This screen finalizes the encounter information and concludes the progress note. It also specifies the type of visit for billing purposes. The diagnostic and procedure details presented here will correspond with those in the billing section.
Access
Through Main Menu
- Click on the 'Clinical' tab in the main menu.
- Choose a patient from any section within the 'Clinical Records' screen.
- Once the clinical evaluation is complete, click the 'Save' button located at the top of the screen.
Sections
Buttons
- Add Dx: Enables the addition of diagnostics to the "Today's Dx" section.
- F Codes: The Encounter Procedures section may incorporate F codes, applicable based on diagnoses, vital records, and various other factors.
- HEDIS F Codes: Allows for the inclusion of F codes as applicable from HEDIS.
- Signatures: This system enables the registration of a patient's signature or that of a relative or legal guardian if the patient is a minor, for display in the progress note.
- Patient Signature: Enables the registration of the patient's signature.
- Parent or tutor signature: Enables the registration of a relative's or legal guardian's signature.
- Frequent Procedures: Enables the addition of frequently used provider procedures that have been previously configured.
- Note: To configure frequent codes, go to Settings > General > Staff & Providers, select the desired provider, and click on the 'Close Encounter Code Settings' button.
- Add Procedures: Enables the addition of more procedures performed during the encounter.
- Leave Note Open: Enables keeping the progress note open.
- Save and Close: Enables saving and closing the progress note. (Recommended))
- Note: Once the progress note is closed, it cannot be altered. Only one addendum or amendment will be permitted.
- Previous: Closes the screen.
Sections
- Billable Problem List: This section will display the diagnoses to be billed for the encounter.
- Todays Dxs: This section will display the diagnoses added during the clinical evaluation of the current encounter.
- Patient Current Diagnosis: This section displays the patient's active diagnoses.
: This function enables the copying of diagnostics from the Patient Current Diagnosis section to the Encounter Billable Problem List section for use in billing.- Meaningful Use Summary Settings: This section is designated for the upload of various Meaningful Use measurements.
- Auto-upload clinical summary for this patient: Selecting and saving a closed progress note will automatically send the clinical summary to the patient portal.
- Note: To accomplish this, you must register the "Direct" email through the patient portal on the "Patient Details" screen.
- Print Clinical Summary (PDF): Upon selecting and saving the closed progress note, the Clinical Summary will be displayed for delivery to the patient.
- Direct: The patient's portal address, which is registered on the Patient Details screen, will be displayed.
- Email: The patient's registered email will be displayed on the Patient Details screen.
- Auto-upload clinical summary for this patient: Selecting and saving a closed progress note will automatically send the clinical summary to the patient portal.
- Encounter Procedures: In this section, the procedure codes selected for the encounter will be displayed. To use the Default Codes, check this box if you wish to use the previously configured default codes.
- Assessment / Plan: In this section, the Assessment and the Plan, both of which were created in 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 copy the codes to the Encounter Procedures section. The user will have the option to configure which codes are displayed in this section.
- Note: User preference codes will be displayed in this section once they are configured in Settings > Clinical > Closing Procedures Settings.