Adding medical encounters

You can attach medical encounters to a patient's record. Encounters correspond to AMA-CPT, ICD-9-CM, SNOMED, HCPCS, and LOINC codes. You can use medical encounters to determine clinical quality measures, which can be sent electronically to a recipient.

Note: Accessing a patient's medical encounters requires the "Medical Encounters, Open" security right. Adding medical encounters requires the "Medical Encounters, Enter" security right.

To add medical encounters

With a patient selected in Chart, do one of the following:

Click the Medical Encounters button on the toolbar.

On the File menu, click Medical Encounters.

If applicable, do one of the following:

If the Password - Medical Encounters, Open dialog box appears, user verification has been assigned to the "Medical Encounters, Open" task. Do one of the following:

If your user account has been granted the "Medical Encounters, Open" security right, enter your credentials in the User ID and Password boxes, and then click OK.

If your user account has not been granted the "Medical Encounters, Open" security right, have a user with permission temporarily override this restriction so you can access medical encounters this one time. The overriding user enters his or her credentials in the User ID and Password boxes and then clicks OK.

If a message appears, informing you that you do not have rights to this operation, your user account has not been granted the "Medical Encounters, Open" security right. To have a user with permission temporarily override this restriction so you can access medical encounters this one time, do the following:

On the message, click Yes.

In the Password - Medical Encounters, Open dialog box, the overriding user enters his or her credentials in the User ID and Password boxes and then clicks OK.

The Medical Encounters dialog box appears.

Click the Add button .

If applicable, do one of the following:

If the Medical Encounters, Enter dialog box appears, user verification has been assigned to the "Medical Encounters, Enter" task. Do one of the following:

If your user account has been granted the "Medical Encounters, Enter" security right, enter your credentials in the User ID and Password boxes, and then click OK.

If your user account has not been granted the "Medical Encounters, Enter" security right, have a user with permission temporarily override this restriction so you can add medical encounters this one time. The overriding user enters his or her credentials in the User ID and Password boxes and then clicks OK.

If a message appears, informing you that you do not have rights to this operation, your user account has not been granted the "Medical Encounters, Enter" security right. To have a user with permission temporarily override this restriction so you can add medical encounters this one time, do the following:

On the message, click Yes.

In the Medical Encounters, Enter dialog box, the overriding user enters his or her credentials in the User ID and Password boxes and then clicks OK.

The Enter Medical Encounter(s) dialog box appears.

Set up the following options for the medical encounters you are adding (these can be changed per medical encounter later if necessary):

Date - The date of a medical encounter. By default, today's date is selected, but you can specify a different date. To change the date, do one of the following:

Enter the correct date (in a m/d/yyyy format) in the box.

To select a date, do the following:

Click the calendar icon to view a month calendar.

Navigate to the correct month using the left and right arrows.

Note: To quickly change the year and month, click the month-year at the top of the calendar, navigate to the correct year using the left and right arrows, and then click the correct month.

Click the correct day.

Provider - The provider for a medical encounter. By default, the provider that is selected for the current charting session is selected for the medical encounter, but you can select a different provider. To change the provider, do the following:

Click the search button .

The Provider Selection dialog box appears.

Do one of the following:

To view a list of all providers, do the following:

Do not enter any search criteria.

Click Show Results to view a list of all primary and secondary providers.

To search for a provider by ID, first name, last name, and/or title, do the following:

Enter the first character or more of a provider's ID, first name, last name, and/or title in the ProviderID, FirstName, LastName, and/or Title boxes, respectively.

Click Show Results to view a list of matching primary and secondary providers.

Note: To clear the list so you can search again, click Search. Then, click Clear Search to clear the search criteria that you entered.

In the list, select the correct provider.

Click OK.

Clinic - The clinic where a medical encounter occurred. By default, the clinic that you are logged in to is selected for the medical encounter, but you can select a different clinic. To change the clinic, do the following:

Click the search button .

Note: This button is available only if your user account has been granted the "My Clinics, View" security right (in the "Practice/Clinic Setup" category) to any clinic.

The Clinic Selection dialog box appears.

If the list is long, to search for a clinic by ID and/or title, do the following:

Click Search.

The options for searching appear.

Enter the first character or more of a clinic's ID and/or title in the ID and/or Practice Title boxes, respectively.

Click Show Results to view a list of matching clinics.

Note: To return to viewing the list of all the clinics, click Search, click Clear Search to clear the search criteria that you entered, and then click Show Results.

In the list, select the correct clinic.

Click OK.

Negation Code (SnoMed) - The negation code that you want to associate with a medical encounter to qualify for exceptions to certain visits for clinical quality measures.

To add one or more medical encounters using codes from a particular set, do one of the following:

For AMA-CPT codes:

In the Double Click a Code Set list, double-click AMA-CPT.

The AMA Code Selection dialog box appears.

Do one of the following:

To view a list of all AMA codes, do the following:

Do not enter any search criteria.

Click Show Results to view a list of all AMA codes.

To search for AMA codes by code and/or description, do the following:

Enter the first character or more of an AMA code and/or description in the Code and/or CodeDesc boxes, respectively.

Click Show Results to view a list of matching AMA codes.

Note: To clear the list so you can search again, click Search. Then, click Clear Search to clear the search criteria that you entered.

In the upper list, select one or more AMA codes.

Note: To select multiple AMA codes, click an AMA  code, and then, while pressing the Ctrl key, click the other desired AMA codes. To select a range of adjacent AMA codes, click the first AMA code of the desired range of AMA codes, and then, while pressing the Shift key, click the last AMA code of the desired range of AMA codes.

Click Add.

Repeat steps b-d as needed to add other AMA codes.

Note: To remove an AMA code that you added, select that AMA code in the lower list, and then click Remove.

Click OK.

For HCPCS codes:

In the Double Click a Code Set list, double-click HCPCS.

The HCPCS Code Selection dialog box appears.

Do one of the following:

To view a list of all HCPCS codes, do the following:

Do not enter any search criteria.

Click Show Results to view a list of all HCPCS codes.

To search for HCPCS codes by code and/or description, do the following:

Enter the first character or more of an HCPCS code and/or description in the Code and/or CodeDesc boxes, respectively.

Click Show Results to view a list of matching HCPCS codes.

Note: To clear the list so you can search again, click Search. Then, click Clear Search to clear the search criteria that you entered.

In the upper list, select one or more HCPCS codes.

Note: To select multiple HCPCS codes, click an HCPCS code, and then, while pressing the Ctrl key, click the other desired HCPCS codes. To select a range of adjacent HCPCS codes, click the first HCPCS code of the desired range of HCPCS codes, and then, while pressing the Shift key, click the last HCPCS code of the desired range of HCPCS codes.

Click Add.

Repeat steps b-d as needed to add other HCPCS codes.

Note: To remove an HCPCS code that you added, select that HCPCS code in the lower list, and then click Remove.

Click OK.

For ICD-10-CM codes:

In the Double Click a Code Set list, double-click ICD-10-CM.

The ICD-10-CM Diagnostic Code Selection dialog box appears.

Do one of the following:

To view a list of all ICD-10 codes, do the following:

Do not enter any search criteria.

Click Show Results to view a list of all ICD-10 codes.

To search for ICD-10 codes by code and/or description, do the following:

Enter the first character or more of an ICD-10 code and/or description in the Code and/or Description boxes, respectively.

Click Show Results to view a list of matching ICD-10 codes.

Note: To clear the list so you can search again, click Search. Then, click Clear Search to clear the search criteria that you entered.

In the upper list, select one or more ICD-10 codes.

Note: To select multiple ICD-10 codes, click an ICD-10 code, and then, while pressing the Ctrl key, click the other desired ICD-10 codes. To select a range of adjacent ICD-10 codes, click the first ICD-10 code of the desired range of ICD-10 codes, and then, while pressing the Shift key, click the last ICD-10 code of the desired range of ICD-10 codes.

Click Add.

Repeat steps b-d as needed to add other ICD-10 codes.

Note: To remove an ICD-10 code that you added, select that ICD-10 code in the lower list, and then click Remove.

Click OK.

For ICD-9-CM codes:

In the Double Click a Code Set list, double-click ICD-9-CM.

The ICD-9-CM Diagnostic Code Selection dialog box appears.

Do one of the following:

To view a list of all ICD-9 codes, do the following:

Do not enter any search criteria.

Click Show Results to view a list of all ICD-9 codes.

To search for ICD-9 codes by code and/or description, do the following:

Enter the first character or more of an ICD-9 code and/or description in the Code and/or Description boxes, respectively.

Click Show Results to view a list of matching ICD-9 codes.

Note: To clear the list so you can search again, click Search. Then, click Clear Search to clear the search criteria that you entered.

In the upper list, select one or more ICD-9 codes.

Note: To select multiple ICD-9 codes, click an ICD-9 code, and then, while pressing the Ctrl key, click the other desired ICD-9 codes. To select a range of adjacent ICD-9 codes, click the first ICD-9 code of the desired range of ICD-9 codes, and then, while pressing the Shift key, click the last ICD-9 code of the desired range of ICD-9 codes.

Click Add.

Repeat steps b-d as needed to add other ICD-9 codes.

Note: To remove an ICD-9 code that you added, select that ICD-9 code in the lower list, and then click Remove.

Click OK.

For LOINC codes:

In the Double Click a Code Set list, double-click LOINC.

The LOINC Selection dialog box appears.

Do one of the following:

To view a list of all LOINC codes, do the following:

Do not enter any search criteria.

Click Show Results to view a list of all LOINC codes.

To search for LOINC codes by code and/or description, do the following:

Enter the first character or more of a LOINC code and/or description in the LOINC_Num and/or Component boxes, respectively.

Click Show Results to view a list of matching LOINC codes.

Note: To clear the list so you can search again, click Search. Then, click Clear Search to clear the search criteria that you entered.

In the upper list, select one or more LOINC codes.

Note: To select multiple LOINC codes, click a LOINC code, and then, while pressing the Ctrl key, click the other desired LOINC codes. To select a range of adjacent LOINC codes, click the first LOINC code of the desired range of LOINC codes, and then, while pressing the Shift key, click the last LOINC code of the desired range of LOINC codes.

Click Add.

Repeat steps b-d as needed to add other LOINC codes.

Note: To remove a LOINC code that you added, select that LOINC code in the lower list, and then click Remove.

Click OK.

For SNOMED codes:

In the Double Click a Code Set list, double-click SNOMED.

The SNOMED Selection dialog box appears.

Do one of the following:

To view a list of all SNOMED codes, do the following:

Do not enter any search criteria.

Click Show Results to view a list of all SNOMED codes.

To search for SNOMED codes by code and/or description, do the following:

Enter the first character or more of a SNOMED code and/or description in the ConceptID and/or FullySpecifiedName boxes, respectively.

Click Show Results to view a list of matching SNOMED codes.

Note: To clear the list so you can search again, click Search. Then, click Clear Search to clear the search criteria that you entered.

In the upper list, select one or more SNOMED codes.

Note: To select multiple SNOMED codes, click a SNOMED code, and then, while pressing the Ctrl key, click the other desired SNOMED codes. To select a range of adjacent SNOMED codes, click the first SNOMED code of the desired range of SNOMED codes, and then, while pressing the Shift key, click the last SNOMED code of the desired range of SNOMED codes.

Click Add.

Repeat steps b-d as needed to add other SNOMED codes.

Note: To remove a SNOMED code that you added, select that SNOMED code in the lower list, and then click Remove.

Click OK.

Repeat steps 3-4 as needed to add medical encounters using codes from other code sets.

Do any of the following as needed:

To deselect all medical encounters that are selected in the list, click Clear Selections.

To remove any medical encounters that you have added to the list, do the following:

Select one or more medical encounters.

Note: To select multiple medical encounters, click a medical encounter, and then, while pressing the Ctrl key, click the other desired medical encounters. To select a range of adjacent medical encounters, click the first medical encounter of the desired range of medical encounters, and then, while pressing the Shift key, click the last medical encounter of the desired range of medical encounters.

Click Delete.

To change the details of any medical encounters that you have added to the list, do the following:

Select one or more medical encounters.

Note: To select multiple medical encounters, click a medical encounter, and then, while pressing the Ctrl key, click the other desired medical encounters. To select a range of adjacent medical encounters, click the first medical encounter of the desired range of medical encounters, and then, while pressing the Shift key, click the last medical encounter of the desired range of medical encounters.

Make the necessary changes to the Date, Provider, Clinic, and/or Negation Code (SnoMed) options as explained in step 2.

To link a medical encounter to a prescription that was entered on the same day as the encounter, do the following:

Select a medical encounter.

Click the Link To search button .

The Record Selection dialog box appears.

In the Double Click a Category list, double-click Prescriptions to view prescription records for the corresponding date.

Select a prescription record, and then click OK.

Note: A given prescription can be associated with only one medical encounter. If another medical encounter is already linked to the selected prescription record, click OK on the message that appears, informing you that it is already linked, to return to the Record Selection dialog box to select a different prescription record or to close the dialog box without linking the medical encounter to a prescription.

To unlink a medical encounter from a prescription, do the following:

Select a medical encounter.

Next to the Link To box and search button, click Remove.

On the confirmation message that appears, click Yes.

Click OK.

All medical encounters that you added are listed as separate medical encounters in the Medical Encounters dialog box.