Entering Encounter Form Data

In order to receive workload credit, you must enter encounter form data when you create a new progress notes, complete a consult, or write a discharge summary.

Note:   Once a note, summary, or consult has been completed, you can only change encounter information directly through PCE software in the VistA roll and scroll.

 

To enter or change encounter form data, follow these steps:

1.   Select the appropriate tab: Notes, Consults, or D/C Summ.

2.   Select New Note, New Summary or select Action | Consult Results...or locate the appropriate unsigned document in the treeview. For the consult or discharge summary, skip to step 4.

3.  Type in a title for the note or summary or select one from the list and press <Enter> .

4.    On the Notes tab, select the Encounter button, Action | Encounter , or Edit Encounter Information from the right-click pop-up menu. On the Consults and D/C Summ tabs, only the Edit Encounter Information item is available on the pop-up menu.

The Encounter form will appear. ( Note about providers with similar first and last names. )

 

5.   Enter all information for the encounter. Select the tab where you want to enter information:

A.)    Visit Type: Enter the Type of Visit, any service connection, and the providers related to this encounter.

1.   Select the Type of Visit tab.

2.   Select the Type of Visit. This may cause further items to appear in the pane to the right.

3.   To further specify what type of visit, select an item under the Section pane. This may cause items to display under the Modifiers pane.

4.   If needed, select a modifier.

5.   Under Visit Related To, if any Service-Connected or Environmental Conditions are available, use the check boxes to indicate any that relate to this encounter.

6.   Highlight providers’ names and add them or remove them as a provider for the encounter if necessary. You can also highlight a provider’s name and make that provider the primary provider for the encounter.

 

B.)    Diagnosis: Enter the diagnoses for this encounter using either Diagnosis Section categories and accompanying diagnoses or use the Other Diagnosis… button to search for a diagnosis. In the Diagnosis Section pane, CPRS displays the sources for prepopulated diagnoses, such as the Problem List Items and any encounter forms your site has set up for the location or clinic. With the Other Diagnosis… button, the provider types all or part of a term and searches for diagnoses containing the specified text. The provider may need to revise the search with a broader or narrower term to locate the correct diagnosis.

1.   For the Diagnosis Section: To use the Problem List Items or other Encounter forms available, select the Diagnosis tab if it is not already selected.

2.   Select the appropriate source if one is available in the list, such as Problem List Items or an Encounter form that your site has made available. When you select the source, the associated diagnoses display in the pane to the right, which will now have the name of the source above the pane.

3.   Use the check boxes to select the appropriate items from the list. As you select a problem or diagnosis, CPRS will check if the item has an active code, a specific code, and is in the right coding system.

 

This screen capture shows the Encounters' Diagnosis tab with emphasis on the hash symbol (#) that indicates an inactive ICD-9 code. If a provider selects the inactive code to add to an encounter, CPRS will prompt the provider for an ICD-10 code and a SNOMED code to update the problemon the Problem List. It also shows ICD-9 codes and SNOMED codes that come from the Problem List. All problems from the problem list now display here.

 

This screen shows a diagnosis on the Encounter form with an inactive code. If the provider selects a diagnosis, CPRS requires the diagnosis to have an appropriate active code. With ICD-10, all items from the Problem List are now displayed on the Diagnosis tab. Providers could see both active and inactive ICD-9 codes and SNOMED-CT codes. All displayed codes can be selected, but CPRS may require the provider to locate an active code or one from a different coding system. For example, if a user selects a SNOMED or ICD-9 code for an encounter after the ICD-10 activation date, CPRS will prompt the provider to locate an appropriate ICD-10 code.

 

If a user selects a diagnosis or procedure with an inactive code, the above dialog will display telling the user that the code is inactive and that the user should change it. This will change after the ICD-10 activation date because the problem will need to be updated from the Diagnosis tab, not the Problem List tab

 

4.   If the item selected can be used to check out the encounter, it will display under the Selected Diagnoses section. Proceed to step 7. If another dialog displays proceed to step 5. If a provider tries to enter a diagnosis or procedure that has aninactive (shown with a hash or # symbol either because the code itself has become inactive or because it is from a superseded coding system) or unspecified code (799.9 in ICD-9 or R69 in ICD-10) associated with it, CPRS does not accept that selection and displays the search dialog for the provider to locate an appropriate diagnosis.

This screen capture shows the Lookup Diagnosis dialog that the provider would use to search for an appropriate diangosis. The line above the Search for Diagnosis field informs the provider what they are searching for. In this case, it reads: This problem references an ICD code that is not active as of the date of this encounter. Please update the ICD Diagnosis.

5.   Enter a term or some text to search and select the Search button. Matching terms will be displayed under the Term pane. Before the activation date, the dialog displays possible ICD-9 codes to check out the encounter. The description, code, and coding system will display. After ICD-10 activation, the dialog will display ICD-10 codes, with the description, code, and coding system.

6.   Highlight the appropriate term and select OK. After ICD-10 activation, providers may see terms displayed with a tree view containing broader terms with a plus sign or arrow that they will need to expand to find a more specific term.

7.    (Conditional) After ICD-10 activation, if the provider updates the ICD code, it may trigger a need to update the problem on the Problem List with a new SNOMED code. If it does, a dialog will display and the provider will need to search for and select a SNOMED term for the Problem list. After the term is selected, the problem list will be updated, but the provider may need to refresh to see the change on the Problems tab.

This screen capture shows the Lookup Other Diagnosis dialog with an arrow indicating the line that shows what the provider is searching for. This line of text changes depending on what the provider is searching for: an ICD code or SNOMED code.

Note:    If the provider cancels the process when selecting a SNOMED term, the entire process is canceled, including the ICD code selection that was previously performed.

8.   After CPRS has a valid code, the code will display in the pane below with its name, coding system, and code. The first diagnosis you choose will be the primary diagnosis by default.

9.   If you need to change a different diagnosis in the list to be the primary diagnosis, highlight the item and select the Primary button.

10. If a diagnosis has been entered mistakenly, highlight the diagnosis and select Remove.

11. If you need to add a comment, type it into the Comment field.

-OR-

 

1.   To use the Other Diagnosis… button to select a diagnosis: Select the Other Diagnosis… button. CPRS now displays the Lookup Diagnosis dialog.

2.   In the Search for Diagnosis field, type a term or some text that refers to the diagnosis (such as “diabet” for diabetes) and select Search. The Lexicon is then searched and a list of matching terms is displayed. Plus signs next to terms indicate that there are terms underneath it that are more specific or synonymous. When the user highlights a term, the term, coding system and code are displayed below the list of terms.

This screen shot shows the Lookup Diagnosis dialog with a search term and the resulting list of possible matches. The list has terms with plus signs next to them that can expand.When a term is selected, the term, with its coding system, and code are displayed below the possible matches. Below that information, the number of matches found for the search term is also displayed.

The Lookup Diagnosis dialog enables users to search for the appropriate term to describe the patient’s condition. As shown above, after ICD-10 activation, the results will be in a tree view and providers may need to expand the category to locate a specific term. If too many terms are found, CPRS will prompt the user to be more specific.

 

3.    If appropriate terms are not found, refine your search terms and select Search again.

4.   Highlight the appropriate diagnosis. If the display shows a tree view, note that you must select a specific term and not an item with a plus sign in front of it. When a term is highlighted, the diagnosis is then displayed below the Term pane with its term, code, and coding system. Verify that this is the diagnosis you want. If not, locate the best term. If it is, select OK. The diagnosis will then be added to the pane below the Other Diagnosis… button, showing the name of the term, the coding system, and the code.

 

 

This screen capture show the Encounters' Diagnosis tab with emphasis on the hash symbol (#) that indicates an inactive ICD-9 code. If a provider selects the inactive code to add to an encounter, CPRS will prompt the provider for an ICD-10 code and a SNOMED code to update the problemon the Problem List. It also shows ICD-9 codes and SNOMED codes that come from the Problem List. All problems from the problem list now display here.

This screen shot shows the Lookup Diagnosis dialog with a search term and the resulting list of possible matches. The list has terms with plus signs next to them that can expand.When a term is selected, the term, with its coding system, and code are displayed below the possible matches. Below that information, the number of matches found for the search term is also displayed.

This screen shows a diagnosis on the Encounter form with an inactive code. If the user selects a diagnosis, CPRS requires the user to select an appropriate active code. All items from the Problem List are now displayed on the Diagnosis tab. Providers could see both active and inactive ICD-9 codes and SNOMED-CT codes. All displayed codes can be selected, but CPRS may require the provider to locate an active code or one from a different coding system. For example, if a user selects a SNOMED or ICD-9 code for an encounter after the ICD-10 activation date, CPRS will prompt the provider to locate an appropriate ICD-10 code.

 

The pound sign, #, shows that a problem or diagnosis has an inactive ICD code assicated with it. If the user attempts to select something with an inactive code, CPRS displays a warning box similar to this one.

If a user selects a diagnosis or procedure with an inactive code, the above dialog will display telling the user that the code is inactive and that the user should change it. This will change after the ICD-10 activation date because the problem will need to be updated from the Diagnosis tab, not the Problem List tab.

 

5.   (OPTIONAL) To add the diagnosis to the Problem List, highlight the diagnosis (to add all use the Select All button), select the Add to Problem List check box. Then, in the dialog that displays, type a few characters of the SNOMED term and select Search, highlight the appropriate entry and select OK.

6.  You may repeat steps 1-5 to add other diagnoses.

7.   The first diagnosis you select will be the primary diagnosis unless you designate another as primary. To designate another diagnosis as primary, highlight the appropriate diagnosis and select the Primary button.

8.   If you add a diagnosis by mistake, highlight it and select Remove.

9.   To add a comment, type it in the Comment field.

 

C.) Procedures: Enter procedures performed using either the pre-populated Procedures Section or the Other Procedures… button.

1.   For the Procedures Section, select a source if one is available in the list. If no sources are listed, use the Other Procedures… button.

2.   Select the procedure or procedures from the list that displays in the pane to the right of the sources.

3.   When a procedure is highlighted and the checkbox in front of it selected, a list of modifiers may display in the pane to the right. Select any necessary modifiers.

4.   You can also highlight a procedure from the Selected Procedures list and add a comment (for each procedure individually), and select a quantity for each procedure.

5.   You can also change the provider for the procedure using the drop-down box.

-OR-

1.   To use the Other Procedure… button, select Other Procedure… button. Type a few characters that refer to the procedure (such as “epidur” for epidural procedures) and select Search.

2.   Highlight the appropriate procedure and select OK. You may repeat Steps 1-2 to add other procedures. The procedures you select display in the text box below under the Selected Procedures column.

3.   You can also highlight a procedure from the Selected Procedures list and add a comment (for each procedure individually), and select a quantity for each procedure.

4.   You can also change the provider for the procedure using the drop-down box.

 

D.)   Vitals: On this tab, users can view vitals or select the Enter Vitals button to record vitals.

Note:       To enter vitals, follow the  instructions in the Entering Vitals topic.

 

E.) Immunizations: Enter immunizations performed using either the pre-populated Immunizations Section or the Other Immunization… button.

1.   For the Immunizations Section, select a source if one is available in the list. If no sources are listed, use the Other Immunization… button.

2.   After selecting a source, select the check box to the right of the immunization or immunizations from the list that displays in the pane to the right of the sources. CPRS displays the immunization below.

3.   If needed, highlight the immunization and select the series from the drop-down box.

4.   If the patient had a reaction, use the Reaction drop-down box to indicate the reaction.

5.   If the immunization should not be repeated, highlight the immunization and select the Repeat Contraindicated check box.

6.   To add a comment, highlight the appropriate immunization, move the cursor to the Comments field, and type in your comment.

-OR-

 

1. To use the Other Immunization… button, select Other Immunization… button. From the dialog that displays, select the appropriate immunization and select OK. Repeat this process if necessary to add all immunizations given to the patient.

2.   After you select OK or select the check box, the immunization is added to the list below.

3.   If needed, highlight the immunization and select the series from the drop-down box.

4.   If the patient had a reaction, use the Reaction drop-down box to indicate the reaction.

5.   If the immunization should not be repeated, highlight the immunization and select the Repeat Contraindicated check box.

6.   To add a comment, highlight the appropriate immunization, move the cursor to the Comments field, and type in your comment.

 

F.)  Skin Tests: Enter skin tests performed using either the pre-populated Skin Tests Section or the Other Skin Test… button.

1.   For the Skin Tests Section, select a source if one is available in the list. If no sources are listed, use the Other Skin Test… button.

2.   After selecting a source, select the skin test or skin tests from the list that displays in the pane to the right of the sources. CPRS displays the skin test in the pane below.

3.   If needed, highlight the skin test and select the Results from the drop-down box.

4.   If necessary, use the Reading drop-down box to enter the reading.

5.   To add a comment, highlight the appropriate skin test, move the cursor to the Comments field, and type in your comment.

-OR-

 

1.   To use the Other Skin Test … button, select Other Skin Test… button.

2.   From the Other Skin Test dialog, select the appropriate skin tests and select OK.

3.   After you select OK or select the check box, the skin test is added to the list below.

4.    If needed, highlight the skin test and select the Results from the drop-down box.

5.    If necessary, use the Reading drop-down box to enter the reading.

6.   To add a comment, highlight the appropriate skin test, move the cursor to the Comments field, and type in your comment.

 

G.)  Patient Ed.: Enter any patient education tasks performed using either the pre-populated Patient Education Section or the Other Education Topic… button.

1.   For the Patient Education Section, select a source if one is available in the list. If no sources are listed, use the Other Education Topic… button.

2.   After selecting a source, select the education topics from the list that displays in the pane to the right of the sources. CPRS displays the education topic in the pane below.

3.   If needed, highlight the education topic and use the drop-down box to the enter a Level Of Understanding.

4.   To add a comment, highlight the appropriate education topic, move the cursor to the Comments field, and type in your comment

-OR-

 

1.   To use the Other Education Topic… button, select Other Education Topic… button.

2.   From the Other Education Topics dialog, select the patient education topic and select OK. Repeat this process if necessary to add all education topics given to the patient.

3.   After you select ok or select the check box, the education topic is added to the list below. If needed, highlight the education topic and use the drop-down box to the enter a Level Of Understanding.

4.   To add a comment, highlight the appropriate education topic, move the cursor to the Comments field, and type in your comment.

 

H.) Health Factors: Enter any health factors for this patient using either the pre-populated Health Factors Section or the Other Health Factor… button.

1.   For the Health Factor Section, select a source if one is available in the list. If no sources are listed, use the Other Health Factor… button.

2.   After selecting a source, select the health factor from the list that displays in the pane to the right of the sources.

3.   If needed, highlight the health factor and use the drop-down box to enter a level or severity.

4.   To add a comment, highlight the appropriate health factor, move the cursor to the Comments field, and type in your comment.

-OR-

 

1.   To use the Other Health Factor… button, select Other Health Factor… button.

2.   From the dialog that displays, select the health factor and select OK.

3.   Repeat this process if necessary to add all health factors for the patient. After you select OK or select the check box, the health factor is added to the list below.

4.   If needed, highlight the health factor and use the drop-down box to enter a level or severity.

5.   To add a comment, highlight the appropriate health factor, move the cursor to the Comments field, and type in your comment.

 

I.)  Exams: Enter any examinations performed for this patient using either the pre-populated Exams Section or the Other Exam… button.

1.   For the Exam Section, select a source if one is available in the list. If no sources are listed, use the Other Exam… button.

2.   After selecting a source, select the examination from the list that displays in the pane to the right of the sources.span>

3.   If needed, highlight the exam and use the drop-down box to enter a result.

4.   To add a comment, highlight the appropriate exam, move the cursor to the Comments field, and type in your comment.

-OR-

 

1.   To use the Other Exam… button, select Other Exam… button. From the dialog that displays, select the examination and select OK. Repeat this process if necessary to add all exams for the patient.

2.   After you select ok or select the check box, the exam is added to the list below.

3.   If needed, highlight the exam and use the drop-down box to enter a result.

4.   To add a comment, highlight the appropriate exam, move the cursor to the Comments field, and type in your comment.

5.   When finished, click OK.

 

 

Related Topics

Entering Current Activities Encounter

Encounter Information (overview)

Entering Encounter Form Data on the Procedures tab

Other Health Factors