Clinical Notes

In this area, you will find uploaded documents (consults, referrals, discharge summaries, encounter notes, progress notes, and H&Ps), electronic documents (consults, referrals, discharge summaries, procedures, progress notes, transcribed notes, and H&Ps), and finalized and signed encounter notes for a patient.

Care360 EHR utilizes the Subjective, Objective, Assessment, and Plan (SOAP) format for encounter notes. The SOAP format include four types of data that provide specific information about a patient visit:

• Subjective. Subjective information includes the reason for the patient visit. It may also include the patient’s chief complaint and history of the present illness, problems (diseases, ailments, chronic conditions, upcoming surgeries, etc.), any procedures, conditions, or behaviors which may affect the patient’s care (such as family history, social history, surgical history, past medical history, pregnancy history, and menstrual history), allergy and adverse reaction information, active medications, information gathered during review of the patient’s systems (such as problems related to their cardiovascular or respiratory systems), and any notes, such as patient-provided information.

• Objective. Objective information includes the patient vitals, cognitive/functional status, information gathered during a physical examination, pregnancy-related data, lab results, implanted devices, and any notes that you want to add regarding your clinical observation of the patient.

• Assessment. Assessment information includes diagnoses (and any related notes for the diagnoses that you want to add) and risk evaluations.

• Plan. Plan information includes a description of your treatment plan for the patient. Care360 EHR provides links to write a prescription, order a lab result, document a procedure, document pregnancy-related lab or education data, document a plan of care, document referrals, or access medication or clinical education materials.

Care360 EHR provides you with the ability to start an encounter note from a blank template or to use information from a patient's existing encounter note as a basis. If you choose to start a new encounter note from a patient's existing encounter note, you can copy the following information (when available) into the new encounter note:

• Visit Type

• Responsible Provider

• Location

• Reason for Visit

• CC & HPI

• History (Past Medical History, Pregnancy History, Menstrual History, Surgical History, Social History, and Family History)

• Review of Systems

• Subjective Text

• Physical Exam

• Cognitive/Functional Status

• Objective Text

• Diagnosis

• Assessment Text

• Procedure

• Plan of Care (Plan Text, Assessment and Interventions, Goal(s) and Goal Instructions, Patient Clinical Instructions, Future Scheduled Appointments, and/or Patient Health Concerns)

• Referrals

Encounter notes exist in one of two states: in progress or finalized and signed. An in progress encounter note indicates that an encounter is currently being documented. A finalized encounter note indicates that the documentation for the patient encounter is complete. In progress notes can be changed; finalized notes cannot. If a finalized encounter note requires more information, one or more addenda can be added.

Notes:   • Only Care360 EHR users with the Manage Encounter Notes permission can start, copy, or edit an encounter note. • If your organization is set up to receive transcription entries, then encounter notes can be created using transcribed information. In addition to subjective, objective, assessment, and plan information, an Additional Comments segment may appear for certain transcribed notes. For more information, see Transcribed Encounter Notes. • If a note is marked with or in the patient summary or when viewing all clinical notes for the patient, then billing details are available for the note. For more information, see Recording Billing Details for an Encounter.

Care360 EHR provides additional support for obstetrics and gynecological care. Encounter note support of these specialties is as follows:

Note: Only Care360 EHR organizations with OB/GYN can manage a patient's pregnancy status or track a patient's menstrual and/or pregnancy history.

• OB header and flowsheets. A header containing key pregnancy data such as estimated delivery date and previous pregnancies, and several obstetric (OB) flowsheets, may appear at the top of an encounter note (in addition to the areas in which the data was captured). The data that can be captured in the header and flowsheets is similar to data captured on the forms most obstetricians use for pregnancy visits. For more information about the OB header and flowsheets, see Using the OB Header and Flowsheets.

Note: The OB header and flowsheets display only when the patient is currently, or was previously, identified as being pregnant. For more information about enabling or disabling OB header and flowsheet features for a particular patient by managing their pregnancy status, see Enabling or Disabling OB Features.

• OB print options. Additional print options are available in the print menu (located in the upper-right corner of the patient summary) for Providers, Clinicians, and Clinical Office Staff, including the following:

• Print OB Data. The Print OB Data option is available when viewing an encounter note for a patient who is currently identified as being pregnant, or when viewing any encounter notes containing OB header and flowsheet data. For more information about printing the OB header and Pregnancy and Labs flowsheet data, see Print the OB Header and Flowsheets.

• Print Antepartum Package. The Print Antepartum Package option is available when the selected patient has at least one in progress or finalized encounter note which was created while they were identified as being pregnant. For more information about printing the antepartum package, see Print an Antepartum Package.

• Pregnancy and menstrual history. When adding history from within an encounter note, two additional history categories, and related line items, are available for capturing OB/GYN data:

• Pregnancy History. Includes items related to a patient’s previous pregnancies.

• Menstrual History. Includes items related to a patient’s menstrual history.

The history categories that appear in an encounter note can be configured to match your organization’s needs. For more information about managing templates for patient histories, see Create a History Section Template.

In addition to information that you manually enter, encounter notes can also be created with transcribed information if your organization is set up to receive SOAP-formatted transcribed documents. The physician that dictates the information will appear automatically in the Associated User list and as the user that last modified the note (until the note is edited again).

Notes:   • If a transcribed note is received for an existing patient, a new encounter note that contains the transcribed information is created for that patient. • If a transcribed note is received for a patient that does not yet exist in Care360 EHR, the patient summary is created and then the encounter note is added to the patient summary with the transcribed information. • If a transcribed note is received, but cannot be accurately matched to a patient, then the encounter note appears in the Unassigned Clinical Data list (that can be accessed from Quick View under the Message Center tab). For more information on resolving unassigned encounter notes, see Resolving Unassigned Encounter Notes.

Transcribed information appears in the appropriate areas of the encounter note for a patient. For example, when a physician dictates specific information for vitals, the appropriate fields of the encounter note will display that information (only one set of vitals can be captured for a transcribed note). If information received in the transcribed note does not fit into an appropriate field in the encounter note, the information will appear in the Additional Comments area that appears at the bottom of the note.

Note: The Additional Comments area only appears when there is transcribed information available to view in this area, and does not appear for manually entered encounter notes.

Transcribed encounter notes display the following additional information at the top of the note:

• Transcriptionist name

• Date that the transcription was received

Once a transcribed encounter note is available, you can view and edit the note as you normally would, as well as finalize the note when it is appropriate. For more information on viewing and editing an encounter note, see Update an Encounter Note .