# Entering Encounter Form Data

In order to receive workload credit, you must enter encounter form data when you create a new progress not es, complete a consult, or write a discharge summary.

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

To enter or change encounter form data, follow these steps:

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

2. Select New Note, New Summary or select Action | Consult Results...or locate the appropriate unsigned document in the treeview. For the consult or discharge summary, skip to step 4.

3. Type in a title for the note or summary or select one from the list and press <Enter>.

4. On the Notes tab, select the Encounter button, Action | Encounter, or Edit Encounter Information from the right-click pop-up menu. On the Consults and D/C Summ tabs, only the Edit Encounter Information item is available on the pop-up menu.

The Encounter form will appear. (Note about providers with similar first and last names.)

5. Select the tab where you want to enter information (Type of Visit, where you can also enter the primary and secondary providers, Diagnoses, where you can have diagnoses automatically be added to the Problem List, Procedures, Vitals, Immunizations, Skin Tests, Patient Ed., Health Factors, or Exams).

6. Select the appropriate category in the list box on the left and then click the check boxes by the appropriate items in the list box on the right.

-or-

if the section name you want is not shown or the list boxes are empty, use the search feature:

a) Select Other tab name (each tab's button will be labeled differently).

Note: The Type of Visit and Vitals tabs are different. Type of Visit has no button, and Vitals has an Enter Vitals button that brings up Vitals Lite. For help on entering vitals or measurements, use the Help file on the Vitals dialog that appears within CPRS.

b) Locate and double-click the needed item.

Some tabs have a simple list to choose from. Diagnoses and Procedures have a search function. On these tabs, you need to enter the beginning of a term and click Search before double-clicking.

Note: If a user tries to enter a diagnosis or procedure that has an inactive code associated with it, CPRS will not accept that selection and will request that the user change it. Also, although it is based on ICD-9-CM codes, the Other Diagnosis... button will now search the SNOMED Concept Terms (SNOMED CT) Problem List data set, which should enable clinicians to better find the term they need. If the list does not show the item you are looking for, you can select the Extend Search button to search the ICD-9-CM file. All terms returned by this search must map to ICD-9-CM codes so you may not see a code that has a related SNOMED CT term and code, but you will see an ICD-9-CM code. If a provider enters a diagnosis with or problem that has a 799.9 code (something undefined), a notice will be sent to the Standards and Terminology Service and a new mapping will be created. When available, the 799.9 code will automatically be updated to the new code.

7. Enter any additional information as needed.

Several tabs have additional features, such as drop-down lists for results of exams, severity of problems, and so on.

8. Fill in information for other tabs as needed by repeating steps 2-6.

9. When finished, click OK.

Related Topics

Entering Current Activities Encounter

Encounter Information (overview)

Entering Encounter Form Data on the Procedures tab

Other Health Factors