Run a visit with Encounters
Write the SOAP note for today's visit and keep its prescriptions, labs, and diagnoses together.
Useful for Doctor Clinic admin Secretary
- Open the patient and go to the Encounters tab, then choose Start encounter (for staff where the clinic runs a patient queue, Clinical intake; a doctor always starts an encounter). It is offered while no visit of today is still open.
- Fill in the note: Chief Complaint, History of Present Illness, past and family history, the vitals and Physical Examination Findings, then the Assessment note and Plan note. Later, Edit on a part (Subjective, Objective, Assessment or Plan) opens the note at that part; a part not written yet says so and has its Edit too. A draft is kept as you type: if the window closes, Restore brings it back.
- While today's encounter is open, what you issue for the patient (a prescription, a lab order, a diagnosis) joins it. The note's sections have buttons for it without leaving the visit: + Upload result (Objective), + Diagnosis (Assessment, until the visit has one, the AI's from an uploaded result included: then its pencil adds more, one per line), + Prescription, + Lab order, + Med cert and + Referral (Plan). While the visit is open, a part's Edit also shows a pencil beside each diagnosis, prescription, lab order and referral, which opens it to change. After a prescription or medical certificate joins it, lab results uploaded in the week before that belong to no visit are offered for attaching (Attach all or Keep standalone).
- Choose Save SOAP to keep the note, then Complete when the visit is done. A doctor can use Complete & sign to do both in one step, and Print note prints it.
- A signed note is locked. To correct it later, a doctor uses Add addendum; Reopen brings back a completed, unsigned one.
- The encounter's More menu has Link record, Change visit type, Change visit date, Remove empty visit and Void encounter, where they apply.
- A doctor or clinic admin can add a record saved on its own to a visit with More › Link record (it lists all the patient's standalone records, the nearest to the visit first; one neither dated nor added within 3 days of the visit is marked, and you confirm it before it is linked), or take one off with the remove button beside it (shown once you choose Edit) while the visit is still open. A record taken off stays in its own tab. On a computer, a prescription, lab order, referral or medical certificate in the note has a printer icon beside its pencil: it prints the PDF without opening the record.
Common questions
Why is there no Sign button?
Only a doctor can sign, the note must be completed first, and Doctors can sign encounter notes must be on in Clinic Settings › General.
Can I change a note after it is signed?
Not the note itself. A doctor adds a dated addendum instead (Add addendum).
My prescription did not join today's encounter.
It joins only an encounter that is still open for that date. If none was open, it was saved on its own. When you then open today's encounter, you are asked whether to attach what you saved (Attach all or Keep standalone), and you are asked again each time you open it until you answer: closing the box another way, or closing the app, does not count as an answer; later, More › Link record on the encounter adds it.
The visit was yesterday, but the encounter says today. Can I change the date?
Yes, a doctor or clinic admin can: More › Change visit date. It works while the encounter is not yet completed or signed (reopen a completed one first), can go back up to 30 days, and is not available for a visit that came from the queue.
I started an encounter and closed the note. Where did it go?
Closing only shuts the editor: the encounter stays open and empty. Remove empty visit in its More menu takes it away.
A lab result in the note is wrong. Where do I fix it?
Open Result files in the note. Beside a result you may change: Edit info (an outside result's type, exam date or visit, on Results & Images), Edit result (its values, for whoever encodes it) or Change report (an APE / PEME report).
I uploaded a lab result today but it was not offered for today's visit.
A record counts as near a visit when the day it is dated or the day it was added to the chart is within 3 days of the visit, so a result uploaded today for today's visit is offered even if the test was done earlier, and so are the diagnosis the AI wrote from it and the prescription issued from that diagnosis (a record dated more than 30 days from the visit is offered unticked). If it was not offered, open the encounter's More › Link record: it lists all of the patient's standalone records, and one neither dated nor added within 3 days of the visit asks you to confirm before it is linked. The record keeps its own exam date.