Encounter notes document the results of a patient's visit. Using Remedly, you can create multiple encounters, and therefore encounter notes, for a single appointment.
In this article you'll learn about:
Starting an Encounter Note
Encounter notes are initiated from the appointment and can be started having the following appointment status:
- Scheduled
- Confirmed
- Checked in
- Checked out
First open the appointment from either:
- the Calendar by clicking on the appointment tile
- the Appointments list by clicking on the appointment ID
The appointment opens. Scroll down the page to hit More Actions
> Start New Encounter in case it is 'Scheduled'.
Note: Both the Start New Encounter blue button and Start New Encounter button inside the Encounters section of the appointment appears when the appointment status is 'Checked in'.
When the status of the appointment is 'Checked out' there's only one place where the Start New Encounter available - inside the Encounters section.
Choose an Encounter Template from the drop-down list.
Note: The existing Encounter Templates in the drop-down list were created during practice onboarding. If you want to add a new Encounter Template, please contact support@remedly.com.
Once you choose the preferred Encounter Template, click Start Encounter.
Encounter Details
Once you click Start Encounter, the encounter note will open in a new tab.
The encounter note contents can be edited or deleted using the Remove button.
You can also add problems to the note in Problem List section.
You can search for the diagnosis either by ICD-10 code or by keyword search. Once you choose the diagnosis, be sure to save your selection. You can also make notes.
An ID will be assigned to the diagnosis. You can add multiple diagnoses to the encounter note.
In Rendered Services, you will see the list of services that were provided during the appointment. They are automatically added from the appointment and you can add additional services If needed.
Within the encounter, you can also cancel the encounter note, as long as it has not been signed.
As well as Cancel the Encounter you can check Encounter Audit Log and print encounter if your patient is asking for the paper version.
Encounter Audit Log
The Encounter Audit Log documents all the changes that were made to the encounter note.
You can also sign the encounter note.
Note: A signed encounter note is not editable and cannot be cancelled.
Before signing the encounter note, you can add some additional notes and then add your signature. Afterwards, be sure to save your changes.
Note: It is not possible to sign a note for another provider using their signature, but you can sign the encounter of another provider using your signature.
Once the encounter note is signed, you will not be able to cancel it.
Add an Addendum to a Signed Encounter
Signed encounters cannot be edited but you can add addendums.
1. When you opened an encounter, scroll down the page.
2. Choose Addendums.
3. Click + Add Addendum.
4. Fill in the Subject and the relevant details. Then click Save.
Each addendum will be listed and can be opened by clicking on the Subject field for viewing.
When opened, the addendum details can be reviewed.
Note: There is no limit to how many addendums can be added to a note.
Also addendums are for office use only and cannot be shared with patients via Remedly.
Print Encounter
In case your patient needs to get a printed version of the Encounter you can easily provide it with the help of Remedly.
To print Encounter:
- Open Encounter
- Click the button More Actions
- Select Print Encounter
- Page with a file that is ready for printing will be opened
- Click on the sign Print to see the printing settings
- Select the settings you need and click the button Print
-
The file will be downloaded to your computer and you can easily print it.
Note: please keep in mind that it will be tracked in Audit Logs, where you can also find the attached version of your printed Encounter
Share encounter information with patient via email
In case you want to share the encounter with your patient you can easily do it after the encounter was signed.
To share encounter with patient via email:
- Click More Actions and select Send Encounter to patient.
- The patient will receive an email with button Go to document to view the shared encounter.
- When the patient follows the button or the link the patient gets to the security page to verify themselves and to get permission to view the document.
- After entering the security code and successful authorization the patient will be able to view and print the encounter.
The encounter note will appear in the appointment window.
You can start an additional encounter note if needed.
All encounters for the patient will be available from the Encounter section in Patient Details.
- Related article:
How to Manage Patient Chart (EHR 2.0)
Adding a Bill
Once an encounter is added, you will be able to add a bill for the appointment. Click the + Add button on the right.
Select the service(s) and click Add bill.
After you click Add bill, you will be taken to the RCM system. From there you can either create a claim or collect payment.
Bills can be added without the encounter note being signed.
Bills created manually from the appointment will be linked to the appointment. Bills can also be created that are not associated with an appointment via the RCM.
If you select Collect Payment in the RCM and input the patient's credit card information, it will be retained as credit card on file.
Note: The credit card details won't be saved as a credit card on file If you send the statement to a patient with the ability to pay via email.
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