# Encounter Information (overview)

CPRS has two kinds of encounter information: visit information and encounter form data.

For each visit (or telephone call) with a patient, you need to enter the provider, location, date, and time. CPRS requires this information before you can place orders, write notes, add to the problem list, and so on.

The parameter, ORWPCE ANYTIME ENCOUNTERS, can be set to allow encounters to be entered on the Notes tab when no note is being entered. This will allow encounter entry (at the time of the visit) for dictated not es. This parameter can be set at the User, Service, Division, and System levels. Note that this will edit the encounter associated with the current location and time, which is not necessarily the encounter associated with the currently displayed note.

To receive workload credit, you must enter the encounter form data, including the following information, for each encounter:

· Service connection

· Provider name

· Location

· Date

· Diagnosis

· Procedure

· Visit Information

CPRS shows the encounter provider and location for the visit on the Visit Encounter box, identified in the graphic by the pointer. You can access this box from any chart tab.

If a provider or location has not been assigned, CPRS will prompt you for this in formation when you try to enter progress notes, create orders, and perform other tasks.

Encounter Form Data

To get workload credit and gather information, enter encounter form data whenever you create a progress note, complete a consult, or write a discharge summary. When you create one of these documents, an Encounter button appears. Select this button to bring up the Encounter Form. (Otherwise, you will be prompted for encounter information when you try to sign the note or exit the current patient's chart.

The Encounter Form has the following eight tabs:

· Visit Type

· Diagnoses

· Procedures

· Vitals

· Immunizations

· Skin Tests

· Patient Education

· Health Factors

· Exams

· Global Assessment of Functioning (GAF) (The GAF tab is available only if specific Mental Health patches are installed and if the location is a mental health clinic.)

Your site defines forms from the Automated Information Collection System (AICS) application to be used wit h the Encounter Form. Once your site has defined the necessary forms and associated them with the Encounter Form, each tab has a number of general categories on the left. When you click a general category, the corresponding items appear in the list box on the right.

For example, the Visit Type tab might have New Patient, Established Patient, and so on listed in the left list box. The list box on the right would then have check boxes for the different types of patient appointments, such as Brief Exam, Limited Exam, Intermediate Exam, Extended Exam, and Comprehensive exam.

Even if you have not defined the form, you can click the Other button to get a list of choices that are active on your system.

When the forms are defined and associated with the Encounter Form, you can use the Encounter Form just as you would a paper form: just click the appropriate tab, category, and check boxes to mark items or click Other and select the appropriate choice. On the Visit Type tab, a provider can indicate if the encounter is related to the various exemption categories, such as Service Connected, Combat Veteran, Agent Orange exposure, Ionizing Radiation exposure, Southwest Asia Conditions, Shipboard Hazard and Defense, Military Sexual Trauma, and Head and/or Neck Cancer. If these forms have not yet been defined, ask your Clinical Coordinator for assistance.

Related Topics

Entering Encounter Form Data

Entering Current Activities Encounter