Encounters

To check the information in the Encounters section, follow the steps below and do not forget to complete the required fields (*).


 

Appointments

• Appointments: To view Patient's Appointments History, double click to the “See all records.”

 

Inactive Hospital Services

• Inactive Hospital Services: To view Inactive Hospital Services, click on See all records”

 

Active Hospital Services

• Active Hospital Services: To view Hospital Services, click on See all records”

 

Patient Goal

• Patient Goal: To add a Patient's Goals, click + New Patient Goal".

• Complete the Patient's Goals. Fields with (*) are required fields and must be completed before save the record. Fields marked with (-) are autocompleted.
  • (*) Start Date: Enter Patient's Goal Start Date.
  • (*) Life Cycle Status: Select Life Cycle Status from: Proposed, Planned, Accepted, On-hold, Completed, Cancelled, Entered-in-error or rejected.
  • Achievement Status: Select ​Achievement Status from: In-Progress, Improving, Worsening, No-change, Achieved, Sustaining, Not-achieved, No-progress or Not-attainable.
  • Category: Select ​Category from: Dietary, Safety, Behavioral, Nursing or Physiotherapy.
  • Goal Priority: Select ​Category from: High-priority, Medium-priority, or Low-priority.
  • (*) Description: Enter Patient's Goal Description.
  • Expressed By: Select Expressed By from the look up list (click  or press Enter). Then Save the record.
  • Click “Save and Close”.

                        Open the Patient Goal created in the previous step.


Click 
 

• Patient Goal Target: To add a Patient Goal Target, click “+ New Patient Goal Target".

• Complete the Patient Goal Target. Fields with (*) are required fields and must be completed before save the record. Fields marked with  (-) are autocompleted.
  •  (*) Measure: Select Measure from the look up list (click  or press Enter). Then Save the record.
  • Due Date: Enter Patient Goal Target Due Date.
  • Enter the Patient Goal Target Detail in one of these fields:

• Detail Boolean.
• Detail Quantity - Detail Quantity Unit.
• Detail Range Low - Detail Range High.
• Detail Ratio.
• Detail String.
• (-) Detail: This field will be autocompleted with the Detail entered previously.
• Click “Save and Close”.​​​​​​

 

Health Concerns

• Health Concerns: To add a Patient's Health Concern, click “+ New Health Concern".

• Complete the Patient's Health Concern. Fields with (*) are required fields and must be completed before save the record. Fields marked with (-) are autocompleted.
  • (*) Patient: This field will be autocompleted.
  • (*) Patient Health Concern: Select Patient Health Concern from the look up list (click  or press Enter).
  • Identify By: Select ​​​​​​​​​​​​​​​Identify by from: Patient, Family Member or Provider.
  • Health Concern Observation: Enter ​​​​​​​Health Concern Observation.
  • Click “Save and Close”.

 

Assessment and Plan of Treatment

• Assessment and Plan of Treatment: To add a Patient's Assessment and Plan of Treatment, click “+ New Assessment and Plan of Treatment."

• Complete the Patient's Assessment and Plan of Treatment. Fields with (*) are required fields and must be completed before save the record. Fields marked with (-) are autocompleted.
  • (*) Patient: This field will be autocompleted.
  • (*) Intent: Select ​​​​​​​​​​​​​​​Intent from: Proposal, Plan, Order or Option.
  • Category Code: Select ​​​​​​​​​​​​​​​Category Code from: Assess-plan
  • Narrative Summary: Enter ​​​​​​​Narrative Summary.
  • Assessment and Plan of Treatment Status: Select ​​​​​​​​​​​​​​​Intent from: Draft, Active, On-Hold, Revoked, Completed, Entered-in-error or Unknown.
  • Click “Save and Close”.

​​​​​​
If you want to clone a previous Assessment and Plan of Treatment, open the record, and click “Edit”.


Then the click .


The record will be cloned.

 

Care Team

• ​​​​​​​Care Team: To add a Patient's Care Team, click “+ New Care Team".

• Complete the Patient's Care Team. Fields with (*) are required fields and must be completed before save the record. Fields marked with (-) are autocompleted.
  • (*) Name: Enter Patient's Care Team Name
  • ​​​​​​​(*) Patient: This field will be autocompleted.
  • Reason Code: Select Reason Code from the look up list (click  or press Enter). Then Save the record. ​​​​
  • ​​​​​​​​​​​​​​​Encounter: Select Encounter from the look up list (click  or press Enter). Then Save the record. 
  • ​​​​​​​Managing Organization: Select ​​​​​​​Managing Organization from the look up list (click  or press Enter). Then Save the record.
  • ​​​​​​​Reason Reference: Enter Care Team Reason Reference.
  • Start Date: Enter Care Team Start Date.
  • End Date: Enter Care Team End Date.
  • Care Team Status: Select ​​​​​​​​​​​​​​​Intent from: Proposed, Active, Suspended, Inactive or Entered-in-error.
  • Click “Save and Close”.
• Open the Care Team created in the previous step.

• Click 
  • ​​​​​​​Care Team Members: To add a Care Team Members, click “+ New Care Team Member".

• Complete the Care Team Members. Fields with (*) are required fields and must be completed before save the record. Fields marked with (-) are autocompleted.
  • Clinic Resource: Select ​​​​​​​Clinic Resource from the look up list (click  or press Enter). Then Save the record.
  • External Member: Select ​​​​​​​External Member from the look up list (click  or press Enter). Then Save the record.
  • (*) ​​​​​​​Role: Select Role from the look up list (click  or press Enter). Then Save the record.
  • On Behalf Of: Select ​​​​​​​on Behalf Of from the look up list (click  or press Enter). Then Save the record.
  • Click “Save and Close”.

 

Care Plan

• Care Plan: To add a Patient's Care Plan, click “+ New Care Plan."

• Complete the Patient's Care Plan. Fields with (*) are required fields and must be completed before save the record. Fields marked with (-) are autocompleted.
  • (*) Name: Enter Patient's Care Plan Name
  • (-) Identifier: This field will be autocompleted after the record is saved.
  • Start Date: Enter Care Plan Start Date
  • End Date: Enter Care Plan End Date
  • Intent: Select ​​​​​​​​​​​​​​​from these values: Proposal, Plan, Order, Option.
  • Context Type: Select from these values: Episode of Care, Encounter
  • Description: Enter Care Plan description
  • (-) Patient: This field will be autocompleted
  • Care Plan Status: Select from these values: Pending, Active, Suspended, Completed, Entered in Error, Canceled, Unknown
  • Click “Save and Close”.

 

• Open the Care Plan created in the previous step.

 

• • Care Plan Activities: To add a Care Plan Activity, click “+ New Care Plan Activity".

• Complete the Care Plan Activity. Fields with (*) are required fields and must be completed before save the record. Fields marked with (-) are autocompleted.
  • (*) ​​​​​​​Name: Insert Care Plan Activity Name
  • (-) Activity Id: This field will be autocompleted after the record is saved.
  • (*) ​​​​​​​Activity Definition: Select ​​​​​​​​​​​​​​​from these values: Plan Definition, Activity Definition, Questionnaire.
  • Activity Description: Enter Care Plan Activity description
  • Activity Start Date: Enter Care Plan Start Date
  • Activity End Date: Enter Care Plan End Date
  • (-) Patient: This field will be autocompleted
  • Practitioner: Select Practitioner from the look up list (click  or press Enter). Then Save the record.
  • Activity Status: Select from these values: Not Started, Scheduled, In Progress, On Hold, Completed, Canceled, Unknown
  • Click “Save and Close”.

 

• • Care Plan Goal: To add a Care Plan Goal, click “+ New Care Plan Goal".

• Complete the Care Plan Goal. Fields with (*) are required fields and must be completed before save the record. Fields marked with (-) are autocompleted.
  • (*) ​​​​​​​Name: Insert Care Plan Goal Name
  • Description: Enter Care Plan Goal description
  • Due Date: Enter Care Plan Due Date
  • Care Plan Goal Status: Select from these values: Preparation, In Progress, Not Done, On-Hold, Stopped, Completed, Entered-In-Error, Unknown
  • (-) Patient: This field will be autocompleted
  • Click “Save and Close”.
• Click “Save and Close”.