Document an encounter

This guide provides step-by-step instructions for clinicians and administrative staff to create, document, and sign off on patient encounters within OpenEMR.

Prerequisites

Before creating an encounter, ensure that:

1. The patient record has already been created in OpenEMR.
2. You have a user account with clinical or provider privileges.
3. The facility and provider schedules are properly configured.

Step 1: Search and Select the Patient

1. Navigate to the top navigation bar or left sidebar menu.
2. Select Finder.
3. Use the search bar to find the patient by Name, DOB, or External ID.
4. Click on the patient's name to open their Patient Dashboard.

Step 2: Create a New Encounter

You can initialize an encounter manually or directly from the calendar schedule.

Option A: From the Patient Dashboard

1. On the patient dashboard, navigate to the Patient Encounters in the patient header. You will have a dropdown of the all past patient encounters.
2. Click + next to the dropdown to create an ad hoc encounter.
3. Fill in the Encounter Form header details:
   • Visit Date/Time: Defaults to current date/time.
   • Facility: Select the service facility location.
   • Category: Select the encounter type (e.g., Established Patient, New Patient, Follow-up).
   • Provider: Select the rendering clinician.
   • Sensitivity: Set access restrictions if applicable (e.g., Normal, High).
   • Reason for Visit: Enter the reason for visit.
4. Click Save.

Option B: From the Calendar Schedule

1. Locate the patient’s appointment on the Calendar.
2. Click on the appointment block.
3. Click Arrived.
4. When the appointment status is updated, you will get a confirmation modal that an encounter was created for the patient. As an admin can configure which appointment statuses will create an encounter.

Step 3: Document Clinical Notes

Once the encounter is active, clinical documentation forms can be attached to the visit record.

1. In the open encounter view, locate the Clinical Forms menu or click Add Form.
2. Select the appropriate form for your clinical workflow:
   • SOAP Note: For standard subjective, objective, assessment, and plan notes.
   • Review of Systems (ROS): For systematic organ system inquiries.
   • Physical Exam: For body system examination findings.
3. Complete the required clinical fields within the selected form.
4. Click Save on each form to attach it to the current encounter.

Tip: If you created a custom layout based form, they will may also be available in this view.

Step 4: Record Vitals

1. Within the active encounter menu, select Vitals (or access Vitals from the patient dashboard).
2. Enter objective measurements:
   • Blood Pressure (Systolic / Diastolic)
   • Pulse / Heart Rate
   • Respiration Rate
   • Temperature
   • Height / Weight (BMI auto-calculates upon saving)
   • Oxygen Saturation ($SpO_2$)
3. Click Save Vitals.

Step 5: Assign Diagnoses and Billing Codes

To ensure accurate medical billing and claims generation, record ICD-10 and CPT/HCPCS codes before closing the visit.

1. Navigate to Administrative > Fee Sheet.
2. Under Select code:
   • Select the level of service. The associated CPT code will be added to the list.
3. Under Search for additional codes
   • Diagnoses (ICD-10): Search and select the primary diagnosis and any secondary conditions addressed during the visit.
   • Service Codes (CPT / HCPCS): Search and select the evaluation and management (E/M) or procedure codes.
4. Assign the primary diagnosis pointer to the corresponding service codes in the Justify field.
5. Update modifiers, pricing, and quantity as applicable.
6. Click Save.

Step 6: Review and Authorize the Encounter

1. Review all notes, vitals, and billing codes in the encounter summary.
2. eSign the note to attest and lock the note.
3. Locking the clinical will guard against unauthenticated modifications. Any changes after locking the note should be done as an amendment.