# Entering Encounter Form Data - Procedu res

To receive workload credit, you enter encounter form data when you create a new Progress Note, completing a consult, or writing a discharge summary for the selected patient. All of the tabs are similar, but the Procedures tab has a small, but important difference.

Note: Once a note, summary, or consult has been completed, you can only change encounter information directly through PCE.

When you select an item from the Procedure Section list box on the left side of the tab, specific items are displayed i n the Section Name list box in the middle. Highlight any item in the Section Name list box and the Modifiers for that Section are displayed (as read-only) in the list box on the right side of the tab. Click on any check box in the Section Name and the Mod i fiers can be selected. Once the Modifiers list box is enabled, you may click on any combination of check boxes. The results of your selections are displayed in the list box at the bottom of the tab.

To enter encounter form data on the Procedures tab, follo w these steps:

1. Select the appropriate tab: Notes, Consults, or D/C Summ.

2. Select New Note, New Summary or select Action | Consult Results....

3. Select Encounter.

4. Select the Procedures tab.

5. Select the appropriate category in the Procedure Section list box on the left.

6. Select on one or more check boxes by the appropriate items in the Section Name list box in the middle.

-or-

If the Section Name you want is not shown or the list boxes are em pty, use the search feature by clicking on Other Procedure. Type in the beginning of a term and click Search, then locate and double-click the needed item.

7. Select on one or more check boxes by the appropriate items in the Modifiers list box in the right. You may accept the default list of modifiers or change them to whatever you need.

8. Enter any additional information as necessary.

9. When finished, select OK.

Related Topics

Entering Current Activities Encounter

Encounter Information (overview)

Entering Encounter Form Data on the Procedures tab

Other Health Factors