Title the Problem (Contact) within an Encounter
Document a New Encounter Using a Form
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 on Contact title of the Encounter
‘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.
| Type the problem title: | How it appears after it is saved: |
Use typing templates as needed in the body of the encounter note. Refer to the following Zendesk Article to review available typing templates in EMR.
To add another Contact to the Encounter Note, click on the New button.
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.
Find All Incomplete Contacts
1. Open Work Centre
2. Click on Contacts tab
3. Set view filter to: Incomplete contacts for me
4. Double-click on the row you would like to edit
Notice that the encounter is (Incomplete)
5. Modify the encounter note as required
6. Click on Complete icon
Notice that the encounter note changes to (Complete)
Related Files:
Enter Measures into New Encounter
Deal with an Encounter Entered in Error
Auto-Save Encounters Troubleshooting