Working in a Legacy Encounter

When you open an encounter and are working in it, your point & click encounter exam is customized to your practice. Most sections can be customized and programmed to accommodate your workflow. There are different variations on most sections that can be programmed. Contact your MIE Implementer if you have any questions or want to change an entry section.
At the top of the encounter, you may have a section named Today’s Encounters. This section lists encounters created today only (today’s date).  If you are working in a dated encounter (dated previous to today’s date) and there are multiple encounters, it will still show open encounters for today’s date only, not the dated encounter you are working on.  Your practice might also have links to launch other exams that may require separate documentation/encounters. These links are found right below the Today’s Encounters section.

Your practice may have the Current Users on Encounter section at the top of the open encounter also. This shows any other user that has this encounter set as ‘current’. Two users can be in the same encounter at the same time. However, they will both have to save/ refresh to see each other’s work.  We would hope both users are not entering the same data, if so; the last person to submit wins. You can release that user(s) from the encounter if you wish.

The top portion is an editable field for Date of Service (DOS), location of this patient’s visit and Provider of who is seeing the patient for this visit. For the Provider drop-down – the Meaningful Use and Pediatric encounter exams use the same option when setting the performing doctor (provider). The input remembers what was last entered and pre-fills it with that value.  The office visit encounter exams use the logged in user to pre-fill the value.  So if a nurse adds an office visit through quick links then her/his name will be selected as the provider.  Unless she/he changes that manually.

When you have the specific point & click encounter exam open on your screen, you can begin entering and documenting data for the patient’s encounter. Again, each section may be customized. There is other help documentation specific to certain sections of encounters available.

Navigating Encounter and Back to Chart

At the top of the encounter you will see tabs. The tabs are named the “sections” the encounter has. You can quickly click a “tab” to advance to that section of the encounter.

• Back to Chart tab: this will be the first tab you see at the top when working in an encounter. You can click that and get to the patient’s chart and get to the patient chart, documents, etc while working in an encounter without losing your work.

• When you click back to chart it shows you the e-chart tabs your system has and can access patient documents quickly. That tab name will change to say Back to Exam and you can click that and the tabs will change to be the encounter section tab names.

When working in the encounter, you can see & utilize the save/save view, etc function buttons at anytime from the top tab section names so you don’t have to scroll to find a “save” function button in the encounter itself throughout.

Var-Tree Entry Method

Most entries are radio buttons, check boxes, dictated, sketch, auto-complete fields or free text fields to enter in. Some sections also have a var-tree method. For example, the ROS section has several specific systems that can be documented pertaining to the patient. To document for a specific category that uses the var-tree method, simply click your mouse on the category/system you wish to document on.

When you click on the section (example, we’ve clicked on respiratory section), it will open up previous programmed choices to select. You can select one or multiple. To select multiple, click the [+] to keep the var-tree open and select multiple items from the tree. You can also free text or add dictation from this opened var-tree for that selection. The add new link will show along with the free text and add dictation links if you have security permission to add new var tree entries. To use the Dictation link, you must have security permission to Add Dictation also.

If you have security to add new var tree items, when you click add new it will popup an editor to add the var tree item you wish.

• Item Type: Whether you want a clickable item or a new submenu. You select either to create a clickable item in the grouping where they clicked the ‘Add New’ or whether it creates a sub-grouping.
  • SubMenu Name (If SubMenu selected): the name of the SubMenu to add to the current grouping. This also will create a clickable item under that grouping, so all other fields apply to that clickable item.
  • Allow Append checkbox (If SubMenu selected): whether or not the ‘+’ icons appear next to clickable items inside this new SubMenu.
• Display Name: what appears in the var-tree popup for them to click on (what is displayed on the screen to select from).
• Text: this is what is inserted on the document after you click the “display name” when working in an encounter.
• Is Normal This allows you to flag this statement as the “normal”.
• Snomed: codified category for this item. Can be used to build reports
• Negative Text: this is what is inserted on the document after you click the “display name” when working in an encounter. It’s the ability to specify ‘negative’ var-tree statements.
• Is Normal This allows you to flag this ‘negative’ statement as the “normal”.
• Snomed: codified category for this negative item. Can be used to build reports
• Exam Section: if using the E&M calculator, which section of the E&M calculator does this item give credit for.
• Age/Gender limitations: allows this item to be specified as only relevant for certain demographics.

Spell Check Var-Tree Selection

Spell check is available in a var-tree programming of an encounter. It is a very small pop-up.
After you click on the var-tree entry and select something, simply right click on that statement that was placed in that selection. A small 3 button toolbar will show up. (Triangle, X and A buttons).
If you click on the statement, it opens it up for you to edit/type in it.  You have to get out of that edit/typing mode to be able to right click it for the spell-check toolbar to pop-up.

You can spell-check var-tree entries (previous programming you already have loaded) and you can spell check free-text entries from the var-tree. When done free-text typing, you can right click on top of that free-text you just typed and spell check it.
If you selected multiple var-tree selections within the same subject, you have to click on each var-tree statement at a time to spell check each one.  The spell check does not encompass the entire verbiage on the line.
The ?triangle button means to close out the toolbar.  You have to click this to make the toolbar go away.
The X button means you want to delete that statement.
The A button means you want to spell check that statement.  Then the normal spell-check blue window appears to ignore, edit, etc.

When you spell-check and it finds something, the list of suggestions will appear in a box. You can change to one of the suggestions, or you can ignore or edit or add that word to your Enterprise Health system’s spell check library. See other help documentation named Spell Check.pdf

Bringing in Previous Data/Entries

Your practice may have encounters set up to display the previous entry/data. The previous encounter entry for the section may show on the right side. This is so you can see what someone entered/documented in the most recent previous encounter of this visit type. If you wish to document the same findings (same entry data), you can quickly just copy over that previous entry from the prior encounter over into this current encounter you are working on. This saves time from re-entering the same information. To copy over previous data, simply click the « button found on the right side. The verbiage/data with the « is what was entered in the patient’s previous encounter and it will be copied over to the left side which is the current open encounter you are working in. Each section/item has its own « button so you would do this individually per section/item.

When you click the « button, you will see all that previous data copy over to the left side. Here you can right click on that verbiage that copied over to spell check it, or simply click on that verbiage that cam over and make any edits or additions you wish to the text. You can also still click the section/item name to open up the var-tree and add a var-tree selection to the copied in data.

Healthwise Patient Education Section

The encounter you are working in may have a Patient Education section. This section has a Healthwise link and when clicked it takes you to the Healthwise website to search for patient education sheets. Based on the patient’s active conditions, a list of patient education sheets will be displayed as helpful use for quick document find/ search capability.

Carbon Copy (CC) Section

The CC (carbon copy) section on an encounter is used to document who you would like to receive a copy of the encounter document. The document can then be tasked to someone in your practice to send out or you can have MIE program automatic faxing out to anyone listed in this carbon copy section (contact your MIE Implementer for setup). You can begin typing in the name of a physician you wish to tie to this Carbon Copy section and it will auto-complete choices. The Role column can be changed to be a drop-down to other roles (family, carbon copy user, oncologist, etc). If need to document other “roles” drop-down choices here, please contact your MIE Implementer. By default the carbon copy user, family physician, and referring physician roles are accessible from the drop-down. Link to Patient can be removed if you use a PM system where you maintain the physicians tagged to a patient. Otherwise link to patient if checkmarked will set that physician to the patient’s demographics tab and overwrite anything already there.

There is a user preference in My Settings that you can set to yes and have the referring & family physician(s) and any other patient physicians (roles) that are already set to the patient’s demographics screen to pre-populate here in the Carbon Copy section of an encounter that is created. That way you don’t have to look up who their referring and/or family physician, etc is or manually re-key in the name(s). You can also remove it from the section even if it pre-populates and you don’t want to send it to that physician. In order to bring in the patient’s physicians listed on their record into this CC section, make sure your my settings preference is set to “yes” for Link Patient Doctors New Enc. If the performing provider is also listed in the CC section, it will not CC the performing user (not needed).

By default, the encounters only bring in the referring physician, family physician and carbon copy roles. You may document other physician roles on patient records (ex: oncologist or psychotherapist, etc) and can contact your MIE Implementer. The MIE Implementer will need to have the programmers make a custom change to your CC section to allow those other “roles” to show in the drop-down, then will need to change the system setting to set all the user role id numbers that are to be brought automatically in to the CC section of the encounter.

Generate Referral Note

If you have noted a referring physician for the patient in the CC (carbon copy) section on an encounter, you can utilize the “Generate Referral Note” feature to create an abbreviated/condensed additional view of the main encounter you are working in and store & save that abbreviated/condensed version of the visit to that referring physician.

To do this click [] Generate Referral Note checkbox. Once you do this, a free text box to type (or dragon or dictate) any narrative notes to be on that document you will send to the referring physician opens. Also you will see a var-tree driven field of “other narrative notes” that you can build pretemplated choices or add more free text.

When you then save and go to the “view” of the encounter, you will see the full encounter document first, then when you scroll down you will see an additional view which is this separate abbreviated/condensed referral note you generated. It will be stored as doc.type REFERRAL in your system once you close & archive the encounter. Make sure that doc.type exists in your Enterprise Health system and is mapped. You can then set up any tasking rules or auto-route rules to have that document sent out.

In this additional view of the abbreviated/condensed version formatted to the referring physician you noted, it formats it in a letter format. It pulls patient identifiers at the top, along with the Narrative Notes & other narrative notes you typed in the "generate referral note" section. It will also pull the "impression" section & notes from the encounter along with the entire "plan" section from the encounter. If you need any letterhead or request different formatting or changes to what this default additional view/document shows, please contact your MIE Implementer as it would be customized billable changes.

View of the Encounter

Warnings Section

You can have a system wide setting turned on to show the patient’s “active warnings” display at the top of the encounter view. If the system setting is turned on, all users will see Active Warnings for the patient from the top of the encounter “view” screen also. It will have a show/hide link for your preference to always show those or hide those. Contact your MIE Implementer if you wish this system setting to be turned on.

Quality Section

The encounter you are working in may have a Quality section on the “view” of the encounter. This is where you can manually checkmark/document the Meaningful Use measure(s) specific for this patient’s encounter you are working in.

Hover your mouse over the help icon in the Quality Measures title for explanation on each column checkbox. * Include column checkboxes mean that the patient fits the criteria and that they should be reported for this measure. * Pass column checkboxes mean that the correct actions were performed and documented to satisfy the rule. If you click pass checkbox first, it will automatically check the corresponding include checkbox also. * Example: If a rule said that all female patients should have a pap smear annually, then a typical female should be ‘included'. If the physician was able to document that a pap had been done, then they could check the box for ‘pass'. If the patient had had a hysterectomy, the physician might override the system-determined ‘include' because they think this patient shouldn't be included for this measure. * Exclusion column checkboxes mean that the patient fits into exclusion criteria for this measure for the visit. They are included, but excluded from pass/fail compliancy. You will still need to report exclusions when attesting and they will be on your calculation page & reports. Only certain NQF/clinical quality measures have exclusions available per CMS guidelines so that is why not all measures have this exclusion checkbox.

Portlet & calculation reports show the exclusions as EXC: then the # of patients in that measure currently.

Starred ( * ) checkboxes, in the Quality Measures window that opens, denotes that the system calculates those automatically, but which can still be overridden by the user. MIE will continue to work to automate more of these. The Quality Measures window excludes self-attest measures.

Printing Scripts & E-Orders from Encounter

After you have worked in the encounter and done documentation and have either saved it or submitted the encounter (see other help documentation Encounters-Archiving-Closing-Rearchiving.pdf) you will be taken to the ‘view’ of the encounter. This is the ‘document view’ of what all you entered and documented in this encounter. You can also get to the ‘view’ by clicking the View (name of encounter) link at the top of your summary toolbar.

When you are in the ‘view’ of the encounter, scroll down to the bottom of the document view and you will see Encounter Options section.

The Encounter Options section shows any ordered meds (prescriptions you started/prescribed in the meds plan section of the encounter), test orders (labs, imaging, etc orders you created plan section of the encounter), or any patient education information (drug guides). Those documents/prescriptions are batched at the bottom of this encounter VIEW for quick printing/faxing or access without having to get out of the encounter and into the separate Enterprise Health module to perform the print/faxing of these documents and/or prescriptions. You can select print individual prescriptions, unprinted med guides, e-orders, or click the Print All right next to the Encounter Options title. If you click Print All it will batch all of the documents/prescriptions listed and send them to the printer/fax queue. The “Print All” button prints anything that has the word “Batch” by it. Therefore, it does not matter if you check or uncheck printed drug guides or not. “Print All” does not print unsent prescriptions because the method to send prescriptions has been changed from faxing to transmitting electronically and prompts the user for the method on those. You can, of course, individually select and batch or uncheck-mark documents that you wish from this summary option.

The Send to NMC member section is available at the end of the ‘view’ of your encounter.

If the system setting to show NMC link in view of the encounter is turned on, you will see the Send to NMC member section.

From the encounter ‘view’ a user can quickly send a CCR document to that patient using NoMoreClipboard. Simply click the POST SUMMARY button from this section and it will then send the electronic CCR to NoMoreClipboard.com for that patient. It will also open another window on your screen for you to print out a page to give the patient with their pick up code if they don’t already have a NoMoreClipboard account or if your Enterprise Health system isn’t linked to NoMoreClipboard through a branded portal. Print off that pick-up code sheet for the patient and they can access their electronic records in CCR format using a free membership & pick-up code process. In order for this POST SUMMARY button to work and send an electronic CCR to NoMoreClipboard.com for the patient, your system must be set up to ‘send’ to NoMoreClipboard.com. Contact your MIE Implementer if you get an error when you click this button. Your MIE Implementer will then get your system set up to be able to push CCR’s to NoMoreClipboard. You can control what observations are submitted on CCR’s also. Contact your MIE Implementer to set up a CCR Sharing flowsheet if want to limit what is on a CCR to be shared.

The Patient Education section is used to print out (or batch) a Clinical Summary of the patient’s encounter visit that day. This is used for Meaningful Use incentive also. Clicking batch or print and when the print job is rendered, it will print a Clinical Summary of that encounter visit for the patient according to Meaningful Use criteria. If your system is set up for Meaningful Use, it will also save this as a document (Archived Clinical Summary) most likely found in the DocSum tab too.

Batching the Encounter View

You can ‘batch’ the encounter document if you’ve archived and closed the encounter. This is a quick way to ‘batch’ that encounter document and print off for the patient or fax to someone while in the encounters screen. In order to see the batch feature, the encounter must be closed & archived and once it gives you the successful message that the encounter has been closed & archived as document (___) then you will see the Batch link on your screen.

Batching an archived encounter document from this screen and the ability to see and use the batch link is driven by a system setting, which is on by default.