How to Create a Patient Encounter

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How to Create Patient Encounters

A provider can open a patient’s chart from the Schedule page (accessing by the button in the heading or Select Patient or Patient Chart items on the Home page) or Incomplete Notes pages.

  • When the provider opens a patient’s chart from the Schedule page, the Note Launcher page is displayed. This page shows patient demographics and options for different types of notes.
  • Progress notesComplete H&PConsult and Procedure notes generate charges.
  • Brief notesWrite prescriptionOrders/Plans and Phone notes will generate documentation, but no charges will be associated with these notes.
  • Chronic Care documents contact with certain Medicare patients.
  • Master Problem List and Past Notes will show the patient’s chart, but will not generate a note.

Face Sheet

The Face Sheet holds the relevant patient information and history that a provider needs to begin an encounter.  

  • The nurse will usually enter most of the information on the Face Sheet, but the provider can also input this information or modify it, as desired.

Note: If the provider opens the patient’s chart before the nurse has finished, the values will not show on the Docpad Face sheet. The nurse will have to send a message to the provider with the vitals information.

  • There are 5 tabs on the Face Sheet.  The first three are explained in detail in the Nursepad reference manual.  Risk Assessment and Patient Risk only apply to certain providers.
    • Hx – History is the default page for the Face Sheet
      • Allergies
      • Advanced Directives
      • Current
        • Vitals
        • Complaints
        • Past Notes (signed)
        • Prevention
        • Results
        • Medical/Surgical History
        • Meds – the patient’s current medications
        • FHx/SHx — Family/Social History taken by nurse or medical assistant
        • Risk Ax – risk assessment form to set risk for this patient
        • Patient Risk – means for provider to set patient risk directly according to clinic defined standards in the Admin module under Patient Risk. 
  • To achieve accurate ICD10 codes, click and review Medications, Family and Social History, Medical/ Surgical History.  Information in these areas will increase the ICD10 codes.
  • The Meds tab allows the provider to review current medications and make appropriate adjustments.  More about medications is discussed in the Rx section.
  • Results area of the Face Sheet contains test results that have not been reviewed with the patient.
    • Click the View button to see the individual tests.
    • Review the test with the patient
    • Click Done and the result is filed.
  • Risk assessment and Patient risk are the means to document information needed for Chronic Care Management (CCM) involving Medicare patients with multiple chronic complaints.

Face Sheet for Procedure Note  

  • The Face Sheet is different for a Procedure Note in that it does not include the Complaints section, as the Face Sheet does for a Progress Note, Complete H&P, and Consult Note.  
  • Notice at the bottom there are not tabs for CC and PE since those are not relevant to a procedure alone.  

Chief Complaint (CC) Tab

  • Chief Complaint is transferred from the Face sheet, but can also be selected on the CC tab. 
  • To add additional complaints, the provider can choose from the Common list, choose from the image, or search in the search window.
  • A Chief Complaint must be entered before continuing the Patient encounter.

History of Present Illness (HPI) Tab

  • There is a HPI template generated for each complaint that has been entered on the CC page which will be shown when you click the HPI tab.
  • Select appropriate findings for that patient by clicking once for positive and twice for negative. 
  • When entering text information in a text box, be brief. If more than 4 or 5 words, use the Other Information section in the lower right.
  • To achieve accurate ICD10 codes, click and review Medical History, Family History, Medications, Surgical History and Social History at the bottom of the HPI page.
  • Information in these areas will increase the ICD10 codes. Information in these areas is added from the Face sheet in either Nursepad or Docpad.
  • Complete the ROS (review of systems) for each patient.
  • To enter findings for the next Complaint for that patient, click the link on the top right hand corner (Change Complaint) and select the appropriate template.

Physical Examination (PE) Tab

  • On the Physical Examination (PE) page, select normal and abnormal findings for the patient.
  • Default settings for PE can be managed from the Home page under Personalize the Software.
  • Select the exam type in the upper left section by adding a green check. This indicates that the provider wants all of their pre-set normals to be selected automatically.
  • Clicking on the arrow next to the exam type brings up the normals and abnormals.
    • For example, the picture below has an image of the Respiratory/Chest exam type.  The normals and abnormals are displayed.  Any of the checked items can be unchecked to individualize the note.

Procedures (PROC) Tab

  • There are two ways to get to the Procedure section of Radekal:  (1) the Proc tab for a Progress Note, a Consult Note, or Complete H&P and (2) Procedure Note from the Patient Verification page when a patient is first selected. 
  • In addition to selecting the appropriate findings, it is very important to select the Procedural coding link, at the bottom left of the screen as shown in the picture above.   Selecting the proper procedure codes ensures complete payment for services rendered. 
  • Click the procedure to show a template of that procedure.  Below we see the selection of a nebulizer therapy for the patient’s bronchitis. 

After clicking the Procedural Coding button, the Procedural coding window appears. To bill properly, a procedural code must be selected.   The procedure code will not show up on the Note, but will be included in the Superbill. 

For example, for a nebulizer procedure, the following could be the Procedural coding page: 

CAREFUL:  Once you have completed selecting procedure indications and hit Done, editing must be done carefully.  To edit a Proc, select it from the Current Procedures list.  If you do a search or select a procedure with the same name from the graph, it will remove the previously created one.

Diagnosis (Dx) Tab

  • The note must have a diagnosis that correctly corresponds with labs or procedures that have been ordered. 
  • Select the Dx in one of the following waysThe Differential list appears based on the Chief Complaint for this patient. 
    • Choose the appropriate specialty from the picture
    • Search using the search field
    • Select Active Problems to list the current complaints
    • Choose from the Common or Differential lists.
  • The Common list is created by the physician as complaints are added to the Hot List. 
  • The generic picture for the patient contains multiple specialties which can be selected to get appropriate options for the diagnosis.  By drilling down through the images, the specific Dx can be selected.
  • The Dx tab will display a list of possible diagnoses when there is a Chief Complaint chosen.  For example here, Betty Boop is suffering from insomnia following the death of her husband so the Chief Complaint(CC) is Insomnia.  Going to Dx brings up a list of related diagnoses. 
  • When Adjustment Insomnia is selected as the Dx, the name and code are shown in the box below the picture. 
  • There is a check mark to indicate this Dx is Active. 
  • If a mistake is made, the X box will remove that Dx from the list. 
  • Clicking on the Annotation icon (three dots in parentheses following the name and ICD-10 code), a popup gives further options for details about this Dx.
  •  Clicking on MDM allows specification of the Medical Decision Making for this encounter.
  • Using the Search box to locate a specific diagnosis is shown below, after the Dx is made. 
  • Patient Risk can be set on the Dx page by clicking the button on the upper right side of the page.
  • Patient Risk parameters are defined for the clinic in the Admin module under Patient Risk.  

Orders Tab

  • Radekal Common Orders includes a search box to find specific orders of any type. 
  • Some orders are broken out into their own sections: 
    • Diagnostic & Other Services
    • Procedural Orders
    • Supplies/Equipment
    • Rehab/Home Health
  • Once an order has been selected, it can be added to My Orders Set on the Change popup for convenience (shown below).  Rather than having to search through a long list, My Orders Set will only list those used often that you’ve chosen. 
  • The CPT/HCPC codes are determined by Medicare/Medicaid.

Review & Schedule Orders/Plans

  • Review & Schedule Orders and Plans allows the provider to verify that the lab is being sent to the correct location.
  • Linkage between Dx and Orders can be managed from the Review and Schedule page, depending on the requirements.    Most linkages are only required for Medicare patients and specified by some labs. 
  • Clicking on No Dx Entered for each order allows you to select the appropriate Dx for this patient encounter.  The link can also be specified from the Note page, but this method is more convenient.  
  • The Change window allows the provider to choose when they want the order carried out, specify intervals, where it will be performed, and who will process the order.
  • Notice the button on the top right called Add to My Orders.  The default is negative, but clicking this button will add this procedure to My Orders Set so it will be more easily selected in the future.

Prescriptions (Rx) Tab

The Rx tab is the central location for managing prescriptions along with the Meds tab on the Face Sheet. The Rx data is based on First Data Bank data, an up-to-date repository of information about pharmaceutical products.  

  • Notice that the Dx choices are listed in the left column.  When a Dx has been made for this patient, the Rx page will include the Dx/Rx tab as the default.  Clicking on each Dx will bring up a list of associated medications, if there are any.
  • Any current medication is shown in the right column including dosage, strength, dispensation, etc. 
    • A medication can be discontinued by clicking on the Discontinue button.
    • Clicking on a medication will allow changes to be made.
  • A prescription can be chosen in several ways:
    • By complaint, as shown in the image above.   
    • By searching, as shown in the image below.  Either enter the name of the medication in the search box or select from one of the listed Therapeutic Classifications for detailed lists of appropriate meds. 
    • From the Hot List that you set up.   A medication is added to the Hot List by clicking the Hot button when you prescribe the medication.  The Hot List can be  modified using “manage” when on the Hot List page.
    • A warning will be shown when the note is signed if the patient has an allergy to the medication, provided it has been noted in the allergy section of the chart.  Other warnings such as avoiding grapefruit juice with a medication will also appear.
    • Alert Rules will appear for certain conditions.  These alerts are set by First Databank, the source of the Rx information.

The section at the bottom of the Medications page is Medication Reconciliation/Hx which can communicate any additional information about the patient’s medications.  It can be used for example during Transition of Care to indicate any changes in medication that should be documented in the patient’s record.  Any relevant documents in the patient’s chart will be listed when Medication Reconciliation/Hx is selected.

  • Once a medication has been selected, the options for prescribing will be displayed in the right column.  The prescriber chooses the exact options for each patient.
  • By clicking on the name of the medication in the left column, a specific combination of dosage and strength, etc. can be clicked to pre-select common options for that medication. 
  • Prescription route will be set according to pre-determined defaults.
  • The patient’s preferred pharmacy will be entered automatically. 
  • This prescription can be documented or signed along with other options such as Notes and Alerts.
  • Notice the Hot button at the bottom which will add this medication to the provider’s Hot List.
  • To Taper a medication, select the Taperbutton in the upper right of the Rx page.
  • Once Taper has been selected, the window will change to allow the provider to choose how much medication they want the patient to take for each taper.
  • To select the next taper, click the Save Taper button.  Continue for the duration. 
  • The Routing is set to a default, in this case E-prescribing, which will automatically send the script to the patient’s preferred pharmacy electronically. 
  • By clicking on the Route shown (on the image above, click on E-prescribe), a page will appear to control the details of routing as shown in the image below. 
  • Controlled substances are handled somewhat differently from non-controlled ones as shown in the image below. 
  • For example, a codeine-based cough medicine is not currently allowed to be e-prescribed so the script will be printed. 
  • Choose where to send the prescription by clicking on the current option: Send to Nurse, Fax to the pharmacy, or Print.  Clicking brings up a page that allows the selection and also allows the choice of applying this option to this Rx only or to all Rx for this patient today. 
  • Once the script has been signed, any new medication will show up in the right column under Prescriptions above the Current Medications.