Adding an Encounter
- After searching and clicking into the client's profile, click 'Encounters' in the menu to the left
- Encounters are any interaction that you have with your client that you would like to have a record of. You can add a new encounter by clicking the 'Add an encounter' button to the top-right of the page
- The first thing you will do is specify what type of encounter this is. As you can see, there are several choices available to you in the dropdown menu. All but 4 of these encounter types has the same layout and we will discuss their significance in the following steps
- Prenatal: this will be used for your active pregnant clients to track information about their vital signs
- Newborn: used to track the baby throughout the postpartum period
- Transfer/Discharge from Care: used when circumstances dictate that the care of the patient should be handled elsewhere
- Labor, Birth, & Immediate Postpartum: used to track events within the labor
- Other: typically used for GYN and well-woman visits
- You have the option of adding a physical exam to any Encounter with the exception of the Transfer/Discharge from Care Encounter. You can do a basic physical examination or choose additional systems from the list below. Simply click the exam type and that section will be expanded for documentation purposes
- If you have added To-Do lists to the client's chart already, you may check off items to keep track of what you have and have not done during an Encounter. This includes the Initial Labor Notes of the Labor Encounter. Clicking the 'Add an item' button at the bottom of any list will allow you to add additional items
- If you would like this encounter to be hidden from the client, check the box next to 'Privacy'. You can also choose to notify all or some of practice members by checking all that apply
- Uploading a file that pertains to this encounter can be done here as well. Please keep in mind that there is a 25MB size limit to the files you upload at any one time
- After saving your entry, you will see a list of all encounters for this client starting with the most recent. You can also edit these entries at any time by clicking the small green square with a pencil in it