You can check out the article here.
0:00 Hi there. In today's video, we are going to be going over how to create a new encounter note. First, we will want to open up the patient's encounter chart, their e-chart.
0:13 That can be done by using the e shortcut on the scheduled appointment and that'll open up to their e-chart here.
0:21 This will open up with a new note with today's date to display for you to create your Note. You can also obtain that e shortcut from a patient search by clicking on the search up at the top.
0:33 I'm just going to search here for a patient and that'll also give us an e shortcut from here in order to create a new note.
0:43 So I'm just going to go into our appointment with the e opening up their chart. Now, should you open up a chart and your cursor is flashing in a note with an old date up at the top, that'll indicate that the note has not been signed yet at this time.
1:00 Now you'll notice above our past note it's showing that I'm not able to place my cursor into it to make any adjustments.
1:15 Should you obtain a, receive a note that has not been signed off from the last encounter that you had with the patient, you would want to utilize one of the sign options.
1:24 So you have the blue arrow with the, the white page, that'll be a sign and save and exit, or you have the pencil and pen.
1:31 And for a verifying sign or a dollar sign with regards to sign, save and bill. So by closing off the note that will ensure that the next time you open up the chart, that you'll receive a new note.
1:42 You also have a new note icon here down at the bottom with the white blank page, and that'll automatically provide you with a new encounter note.
1:52 Just going to go ahead and sign off the old note. And that's going to give us the ability to have a new note.
1:58 And we go back in there, ensuring that the next time we see this patient, that it's going to come up with a new note with today's current date.
2:07 Now in the center here, you are able to start, do a free hand typing in order to create your note.
2:14 You also have templates that you can use. Templates can be searched with the search bar up there on the side by typing in the name of your template and that will populate there into the encounter note section.
2:28 Templates are available in order to be customized at clinic level that you can utilize to make your notes more efficient.
2:35 After you have completed your note, I'm first going to demonstrate just that blue arrow and white page in order to do our sign and save and exit.
2:45 So that's going to close off our chart for us and save our note. Now you'll notice that once we have done that we have received a white box that has appeared behind the appointment status icon on our schedule indicating that we have a signed note for the day.
3:02 With our next patient, I'm just going to go into their chart And we, from here, we are going to utilize this.
3:08 The verify and sign option. Verify and sign would be done when you are reviewing notes that have been entered in by another provider.
3:18 For instance, a resident or a student that you have working at your clinic. So we'll see the previous note here, it was signed off by Dr. Oscardoc. I'm going to click the edit up at the top in order to open up that note. And by opening up that note, I'm going to enter in my revision of it, so I'm signing off on what they have entered in.
3:39 From here, I'm going to utilize the pencil and pen icon for my verify and sign. Now you'll notice that once we have done that, that appointment has received an orange box going in behind the appointment status icon indicating that That note has been verified with our last appointment.
4:03 Here, I'm just going to go into the chart and utilize the last icon, which is a sign and bill option.
4:12 Now, depending on your workflow, if you like to enter in your charting notes and then bill immediately after doing that.
4:20 After doing that, you do have a dollar sign symbol, and that will sign off your note. And open up to the billing page in order for you to complete your bill.
4:35 Now, with the sign, save, and bill option, that will also give you a white box, similar to just the sign, save, and exit.
4:45 but you'll notice that since it has been building up. it has also received a blue check mark. The status has changed to the, the color has changed to the blue status, and it has updated to a negative B symbol for us.
4:58 Now, you'll notice the very top appointment at 8 o'clock has no box behind the appointment status, indicating that there has been no signed note for that date.
5:11 That would be concluding today's video on how to create a new encounter note. You can check out our help portal for additional articles and videos. Thanks!