Here we will be reviewing how to create a new Encounter Note within the patient eChart. Reviewing the different Signing options, and concluding with advisement on visual notifications if an encounter note has been completed.
You can check out the video here.
First, we would need to access the eChart in order to add a new note.
Accessing eChart:
This can be done a number of ways, such as using the E short cut from a scheduled appointment, or on a patient search:
Now that we have accessed the eChart, lets begin our encounter note!
Creating Encounter Note:
The eChart should load with a new note and current date, your cursor should also be populated in the note box to begin typing:
Please note, that when accessing the eChart, if there is an unsigned note from the last encounter with the patient, your cursor will automatically flash and load in that unsigned note:
In order to obtain a new note, we would want to use one of the Sign Off buttons in order to close off the previous note. This will ensure that the next appointment for the patient will load with a fresh blank note with matching date.
The encounter note can be entered, by free-hand typing, using an AI assistance tool, or using a Template.
You can check out this article regarding using Nexus AI tool: Nexus Scribe Encounters
Here is also a link to using Templates: Encounter Note Template
After the encounter note has been entered, it would need to be Signed and Saved!
Sign and Save Options:
An encounter note will have an internal save draft that is completed every few seconds:
If you're exiting the eChart prior to Signing off the encounter note, it is recommended to use the Save icon:
The encounter note can then be completed the next time you open the eChart.
When the encounter note is completed, there are 3 Signing options available, the best one to use would depend on your personal workflow.
The first icon, with the white note pad and blue arrow will Sign and Save the encounter note, and close the eChart window for you.
The second icon, the pens and pencil will complete a Verify and Sign, this can be used to verify another provider's entry in the eChart, such as for a Resident or Student.
Finally, the last icon will complete a Sign, Save and Bill which will open the Invoice Creation page after signing the encounter note and closing the eChart window.
Visual Notification:
From the schedule, after one of the Sign options is utilized, the appointment type will have a box appear behind the icon.
For the Sign and Save, as well as for the Sign, Save and Bill that box will load as white:
Please note, when using the Sign, Save and Bill option the appointment status will update to Billed which will change the colour of the appointment. This will also add a blue checkmark in place of the appointment type icon.
When using the Verify and Sign, the box will be orange:
These Signed appointments can be compared to Unsigned appointments:
If you have any questions, please contact Support at help@oscarprodesk.ca