Documentation/User_Guide/06.html

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   6 <title>OpenEMR v3.2.0 Users Guide - New Encounters & Coding</title>
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  13 <h1>OpenEMR Users Guide (version 3.2.0)</h1>
  14 <h3>Table of Contents</h3>
  15 <ul>
  16 <li><a href="01.html">Getting Started</a></li>
  17 <ul><!-- InstanceBeginEditable name="TOC1" --><!-- InstanceEndEditable --></ul>
  18 <li><a href="02.html">Main Screen & Navigation</a></li>
  19 <ul><!-- InstanceBeginEditable name="TOC2" --><!-- InstanceEndEditable --></ul>
  20 <li><a href="03.html">Setting Up Your Clinic</a></li>
  21 <ul><!-- InstanceBeginEditable name="TOC3" --><!-- InstanceEndEditable --></ul>
  22 <li><a href="04.html">Adding a New Patient</a></li>
  23 <ul><!-- InstanceBeginEditable name="TOC4" --><!-- InstanceEndEditable --></ul>
  24 <li><a href="05.html">Using the Calendar</a></li>
  25 <ul><!-- InstanceBeginEditable name="TOC5" --><!-- InstanceEndEditable --></ul>
  26 <li><a href="06.html">New Encounters & Coding</a></li>
  27 <ul><!-- InstanceBeginEditable name="TOC6" -->
  28 <li>Opening a New Encounter</li>
  29 <li>Encounter Forms</li>
  30 <li>Using the Fee Sheet</li>
  31 <li>Adding Prescriptions</li>
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  33 <li><a href="07.html">Issues & Immunizations</a></li>
  34 <ul><!-- InstanceBeginEditable name="TOC7" --><!-- InstanceEndEditable --></ul>
  35 <li><a href="08.html">Patient Notes & Transactions</a></li>
  36 <ul><!-- InstanceBeginEditable name="TOC8" --><!-- InstanceEndEditable --></ul>
  37 <li><a href="09.html">Basic Billing</a></li>
  38 <ul><!-- InstanceBeginEditable name="TOC9" --><!-- InstanceEndEditable --></ul>
  39 <li><a href="10.html">Accounting & Receivables</a></li>
  40 <ul><!-- InstanceBeginEditable name="TOC10" --><!-- InstanceEndEditable --></ul>
  41 <li><a href="11.html">Reporting</a></li>
  42 <ul><!-- InstanceBeginEditable name="TOC11" --><!-- InstanceEndEditable --></ul>
  43 <li><a href="index.html">Index</a></li>
  44 </ul>
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  52 <h2>New Encounters & Coding</h2>
  53 <p>Patient encounters are  handled primarily by a clinic's providers. </p>
  54 <img src="processed/051.png" />
  55 <p>Logging in as a provider  presents you with the Calendar page showing only that provider's  schedule by default.  To view another provider's schedule, select the  desired user from the list to the left of the calendar. </p>
  56 <p>The bottom window also  shows any notes left for that provider about their patients. </p>
  57 <img src="processed/052.png" />
  58 <p>The Calendar shows the  appointments scheduled for that day.  Providers can see the status of  any given appointment, indicated by the symbol show between the  appointment time and the patient's name.  The “@” symbol, for  example, indicates that the patient has arrived at the clinic and is  ready to begin their appointment.</p>
  59 <h3>Opening a New Encounter</h3>
  60 <p>To begin the encounter,  click on the patients name in the Appointment Calendar.  This brings  you to the patient's Demographics page, as well as the Patient  Summary page which list any notes specific to that patient, and any  medical issues, medications, etc. for that patient.</p>
  61 <img src="processed/053.png" />
  62 <p>Select 'Patient/Client –  Medical Record - History' from the navigation menu to view a summary  of the patients Medical History and Lifestyle information.  Click  'Patient History / Lifestyle (more)' to enter any information that  may be incomplete. </p>
  63 <img src="processed/054.png" />
  64 <p>When you're done, select  'Patient/Client – Visits – List'.  This displays a list of all  encounters that have been entered for this patient.  For new  patients, there may be no encounters listed. </p>
  65 <img src="processed/055.png" />
  66 <p>By default, OpenEMR is set  to generate an empty Encounter when a patient's status has been set  to “Arrived (@)”.  To open this encounter and begin entering  data, click on the new entry in the Encounters list, then click on  'Patient Encounter' next to the provider's name.</p>
  67 <p>If your clinic's version  of OpenEMR is configured differently, you can begin a New Encounter  manually by selecting 'New Visit' from the navigation list on the  left.  Both methods will bring you to the New Encounter Form.</p>
  68 <img src="processed/056.png" />
  69 <p>Here you can enter a brief  description of the encounter and the date of service.  Encounters for  new patients will not have any Issues or Diagnoses associated with  them at this time, so click 'Save' to continue with the encounter.</p>
  70 <h3>Encounter Forms</h3>
  71 <p>This will bring you back  to the summary page for This Encounter.  Displayed is a list of all  the forms associated with this encounter.  You may click on the name  of any of these forms to edit its contents. </p>
  72 <img src="processed/057.png" />
  73 <p>To the right is a  drop-down list of forms that can be added to the encounter.  OpenEMR  comes configured with several common encounter forms by default, but  your clinic may have their own customized encounter forms as well.</p>
  74 <p>Select 'SOAP' from the  drop-down list to add it to the encounter. </p>
  75 <p>The SOAP form will contain  a subjective &amp; objective record of the patient’s vital  information, as well as any  notes on the assessment of the patient's health and suggested  treatment plans.</p>
  76 <img src="processed/058.png" />
  77 <p>Enter the appropriate  information and click 'Save Form' to return to the Encounter summary  page. </p>
  78 <p>You'll see that the SOAP  form has been added to the list of forms for this encounter. Also  shown is a summary of its contents. </p>
  79 <img src="processed/059.png" />
  80 <h3>Using the Fee Sheet</h3>
  81 <p>Next select the 'Fee  Sheet' from the drop-down list.  The Fee Sheet is different  from most other forms in that it enters and modifies billing  information that is stored elsewhere in the system; it is not really  an encounter form, and when used it will not appear in the  encounter's list of forms. </p>
  82 <img src="processed/060.png" />
  83 <p>The Fee Sheet includes  several drop-down lists of the most commonly used billing codes. It  can and should be customized so that it's most suitably adapted to  your practice; </p>
  84 <p>Included is a search  feature, where you can search for and select from the thousands of  billing codes in the database. And below that is a list of all the  billing codes, along with their charges and other related  information, that have been selected for this encounter. </p>
  85 <img src="processed/061.png" />
  86 <p>For example, selecting  'Detailed' from the “New Patient” drop-down adds the associated  CPT code to the list. </p>
  87 <img src="processed/063.png" />
  88 <p>Look for an appropriate  billing code by entering a search term in the box to the left of the  'Search' button.  Make sure the correct code type is selected and  click 'Search'.</p>
  89 <img src="processed/064.png" />
  90 <p>A drop-down list will then  be populated with any billing codes that match your search  parameters.  Selecting the desired code from the list will add it to  the list of codes for this encounter.</p>
  91 <p>The Fee Sheet also allows  you to justify the selected codes for billing purposes.   Justification is the association of ICD9 codes with procedure codes.  Insurance companies require this for billing, in order to &quot;justify&quot;  paying for procedures.</p>
  92 <p>To do this, click the  drop-down menu under 'Justify' for the desired CPT code.  Select the  appropriate ICD9 code from the list and click 'Save'.</p>
  93 <img src="processed/065.png" />
  94 <p>To see the Feet Sheet has  been associated with this encounter, click 'Encounters' in the  navigation menu to go to the list of encounters for this patient.   You can see that the CPT &amp; ICD9 codes are listed next to the new  encounter, as well as the SOAP form that was added earlier.</p>
  95 <img src="processed/066.png" />
  96 <h3>Adding Prescriptions</h3>
  97 <p>To prescribe medication  for this patient select 'Patient/Client – Medical Record - Rx' from  the navigation menu on the left and click 'Add Prescription'.</p>
  98 <img src="processed/067.png" />
  99 <p>This presents you with a  form for entering prescription data, including dosage, refills, and  whether or not generic over-the-counter substitutions are allowed for  this patient. </p>
 100 <p>The Prescription form  includes a search function for looking up a particular type of  medication.  To use this function click 'Drug Lookup'.  A box will  pop up into which a search term may be entered. </p>
 101 <img src="processed/068.png" />
 102 <p>Clicking 'Search' displays  a drop-down list of possible medications generated by  connecting to the web site www.rxlist.com.</p>
 103 <img src="processed/069.png" />
 104 <p>Select the desired  medication to return to the Prescription form.  The selected  medication has now been filled in for you.  Also, clicking 'Yes' next  to “Add to Medication List” will allow the prescription to be  included in the Issues list as a Medication. </p>
 105 <img src="processed/070.png" />
 106 <p>Enter the correct data to  complete the form and click 'Save'.  You are then presented with a  form for generating a PDF of the prescription information.  It may be  printed or sent by email or fax. &quot;Auto Send&quot; will use  whichever default method was selected when you set up the pharmacy. </p>
 107 <img src="processed/071.png" />
 108 <p>Clicking 'Print (PDF)'  will generate the following PDF document to be saved or printed as  necessary.  The default template for this form may also be customized  to your clinic's own specifications.</p>
 109 <img src="processed/072.png" /><br><br>
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