Encounter Notes and Contacts – Profile EMR User Help

Background

Review Previous Encounters

Create a New Encounter

Title the Problem (Contact) within an Encounter

Edit Encounter Properties > Mandatory Encounter Type

Document a New Encounter Using a Form

Document a Late Entry

Find All Incomplete Contacts

Background

The Encounter section of the Client's Medical Record contains the summary of all the client's encounters.

An Encounter is considered any interaction between the Client and the Place of Service (POS). The window displays the Dates of the Encounters, the title of the Contacts, Author of the Encounter. An Encounter can include more than one contact. The issue raised within a visit are referred to as Contacts within Profile EMR.

NEW as of August 28th the Place of Service (POS) where the Encounter was created will be visible in a new column in this window.

Review Previous Encounters

Previous Encounters and Contacts can be reviewed from three areas in the medical record.

1. Use any one of the below methods to review the previous encounters
i. From the toolbar click Review Encounter button OR

ii. From Encounters located within the side segment bar OR

iii. From New Encounter, previous encounters are listed within Recent Contacts (located on the right lower screen)

2. Scroll and click on each encounter to view the details in the right-hand panel of the screen

Create a New Encounter

The New Encounter window is used to record clinical notes about a contact and perform any necessary actions.

There are three options to open a New Encounter in the Medical Record:

Option 1: From the toolbar click New Encounter button

Option 2: Double-click on the patient’s name in the Waiting area or the Appointment booking
of the Work Center, then click New Encounter located within the side segment bar in the Medical Record

Option 3: Click on New Encounter located within the side segment bar in the Medical Record

TIP: To see the Last 5 contacts related to a diagnosis

Title the Contact within an Encounter

To title a Contact, there are various options:

Option 1: Drag and drop the Contact from the Problems list directly onto the default contact title: Contact 1.

If multiple issues are addressed during the client visit, a separate Contact can be created for each issue. If the next issue exists in the Problems List, drag & drop the Contact from the Problems List to the Encounter Note window (this time do not create a New Contact, do not drop directly onto an existing contact title).

Note: While you may document under each Contact Title, it is not mandatory to write a separate progress note for each. A single comprehensive note may be used if preferred.

‘Contact 1 (Complete)’

Complete means you have completed your documentation for the contact of the encounter.

If the document is incomplete and you will need to return to it later to complete, double-click on the word Complete and it will change to Incomplete.

The next time you log back into Profile EMR, you will see a floating counter (Notification Panel) that will remind you that there is an incomplete contact you need to complete documentation in.

Double on the Contact counter and it will bring you the Contacts window within the Work Centre so you can review the list of your Incomplete Contacts for your clients. Double click on the Contact to complete your documentation.

Option 2: Title the Contact using a Coded Contact Title. To do this, simply

i. Type an ICD9 coded diagnosis in the Contact Properties dialogue box shown below. When you type, you will find the results appear in a list.

ii. Double click on the desired ICD9 Code

Option 3: Enter a coded discipline and contact reason in the Contact Properties dialogue box

Option 4: Title the Contact using an Uncoded Contact Title. To do this, simply type a descriptive word or phrase under Problem 1. Start the clinical documentation in the second line.

Use typing templates as needed in the body of the encounter note. Typing templates available in Profile EMR can be found here: Typing Templates

If multiple issues are addressed during the client visit, create a separate Contact for each issue. Each Contact Title can be modified to include the appropriate ICD-9 diagnosis code.

Note: While you may document under each Contact Title, it is not mandatory to write a separate progress note for each. A single comprehensive note may be used if preferred.

To add another Contact within the same Encounter Note, click "New Contact."

Edit Encounter Properties > Mandatory Encounter Type

As of August 24, 2025, following the Profile EMR upgrade to version 9.0.11.A2.4, users may encounter an error when editing Encounter Properties, specifically when attempting to change or backdate encounter dates.

Profile EMR requires an Encounter Guideline/Type to be selected before changes can be saved. If this field is not populated, the save action is blocked.

Workaround:

Change the encounter type dropdown to any type, then switch it back to <None>

Document a New Encounter Using a Form

Use these steps if your clinic has a specific documentation form to record the clinic visit.

1. From the Client's Medical Record New Encounter view, click Form option from the Actions toolbar.

Note: Your most frequently used forms will be automatically added to the Most Used Form Templates section.

2. In the Look for field: enter the name of the form required or some search criteria and click Find button.

3. Double click on the desired form the list as needed.

Document a Late Entry

Adding Clinical Documentation for Late Entry

Create New encounter
Name encounter, “Late Entry” – in Text Description
Add Clinical note
Save
Double click on - Date/time of encounter
Change date to date of service delivered
Select “Type” drop down if not already auto-populated – use Appointment Type, e.g. Nursing etc.
If you are unsure which Type to pick, select any type and then select <None> from the top of the list and this will keep the Type blank but will allow saving.
Click “Ok”