Use encounter plugins

Vitals

Information in the Vitals plugin will automatically pull from the most recently added vitals for the patient.

Click Update on the right side of the plugin heading to re-sync the Vitals information and pull from Vitals & Charting into the encounter.

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Changes to the information in Vitals & Charting will not affect the previously saved entry. Any changes to the Vitals will be added as a new entry to Vitals & Charting once the encounter has been signed.

Patient history

Medical history

Information in the Medical History plugin will automatically pull from the information in the PFSH section under Medical History.

Click Update on the right side of the plugin heading to re-sync the medical history information and pull from the section into the encounter.

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Add specific diagnoses using the + symbol next to the heading.

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In the IMO pop up, search by keyword or description to find ICD-10 codes.

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Click on the + icon to add a diagnosis to the plugin.

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Click on the > icon to narrow down additional diagnosis details.

complex_IMO.png

Select options using the checkbox sections.

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Choose the appropriate diagnosis using the + icon to add it to the plugin.

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Click Free Text to add medical history without linking it to an ICD-10 code.

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Remove medical history using the x icon on the right side of the row.

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Add additional notes in the Other Info section.

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Added and removed medical history will update into the PFSH section once the encounter has been signed.

Hospitalization history

Information in the Hospitalization History plugin will automatically pull from the information in the PFSH section under Hospitalization History.

Click Update on the right side of the plugin heading to re-sync the hospitalization history information and pull from the section into the encounter.

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Add specific diagnoses using the + symbol next to the heading.

Hospitalization_-_add.png

In the IMO pop up, search by keyword or description to find ICD-10 codes.

search_IMO.png

Click on the + icon to add a diagnosis to the plugin.

simple_IMO.png

Click on the > icon to narrow down additional diagnosis details.

complex_IMO.png

Select options using the checkbox sections.

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Choose the appropriate diagnosis using the + icon to add it to the plugin.

__complex_IMO.png

Click Free Text to add hospitalization history without linking it to an ICD-10 code.

Hospitalization_-_free_text.png

Remove hospitalization history using the x icon on the right side of the row.

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Add additional notes in the Other Info section.

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Added and removed hospitalization history will update into the PFSH section once the encounter has been signed.

Surgical history

Information in the Surgical History plugin will automatically pull from the information in the PFSH section under Surgical History.

Click Update on the right side of the plugin heading to re-sync the surgical history information and pull from the section into the encounter.

Surgical_-_plain.png

Add specific diagnoses using the + symbol next to the heading.

Surgical_-_add.png

In the IMO pop up, search by keyword or description to find ICD-10 codes.

search_IMO.png

Click on the + icon to add a diagnosis to the plugin.

simple_IMO.png

Click on the > icon to narrow down additional diagnosis details.

complex_IMO.png

Select options using the checkbox sections.

mceclip0.png

Choose the appropriate diagnosis using the + icon to add it to the plugin.

__complex_IMO.png

Click Free Text to add surgical history without linking it to an ICD-10 code.

Surgical_-_free_text.png

Remove surgical history using the x icon on the right side of the row.

Surgical_-_delete.png

Add additional notes in the Other Info section.

Surgical_-_other.png

Added and removed surgical history will update into the PFSH section once the encounter has been signed.

Implantable device history

Information in the Implantable Device History plugin will automatically pull from the information in the PFSH section under Implantable Device History.

Click Update on the right side of the plugin heading to re-sync the implant information and pull from the section into the encounter.

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Add devices using the + symbol next to the heading. Search the implant device library to add a device. Indicate the appropriate details using the Date, Serial Number, and Status columns.

Implant_-_add.png

Remove devices using the x icon on the right side of the row.

Implant_-_delete.png

Added and removed implantable devices will update into the PFSH section once the encounter has been signed.

Allergy history

Information in the Allergy History plugin will automatically pull from the information in the PFSH section under Allergy History.

Click Update on the right side of the plugin heading to re-sync the allergy information and pull from the section into the encounter.

Allergy_-_plain.png

Add allergies using the + symbol next to the heading. Search the food and drug allergy library to add a device. Indicate the appropriate details using the Reaction, Comments, and other columns.

Allergy_-_add.png

Remove allergies using the x icon on the right side of the row.

Allergy_-_delete.png

Added and removed allergies will update into the PFSH section once the encounter has been signed.

Medication history

Information in the Medication History plugin will automatically pull from the information in the PFSH section under Medication History.

Click Update on the right side of the plugin heading to re-sync the medication information and pull from the section into the encounter.

Medication_-_plain.png

Add medications using the + symbol next to the heading. Search the drug library to add a medication. Indicate the appropriate details using the Dosage, Quantity, Units, Refills, Use Generic, Days Supply, Date, and Comments columns.

Medication_-_add.png

Remove medications using the x icon on the right side of the row.

Medication_-_delete.png

Added and removed medications will update into the PFSH section once the encounter has been signed.

Family history

Information in the Family History plugin will automatically pull from the information in the PFSH section under Family History.

Click Update on the right side of the plugin heading to re-sync the family history information and pull from the section into the encounter.

Family_-_plain.png

Add specific diagnoses using the + symbol next to the heading.

Family_-_add.png

In the IMO pop up, search by keyword or description to find ICD-10 codes.

search_IMO.png

Click on the + icon to add a diagnosis to the plugin.

simple_IMO.png

Click on the > icon to narrow down additional diagnosis details.

complex_IMO.png

Select options using the checkbox sections.

mceclip0.png

Choose the appropriate diagnosis using the + icon to add it to the plugin.

__complex_IMO.png

Indicate the associated family member using the dropdown selection.

Family_-_dropdown.png

Click Free Text to add family history without linking it to an ICD-10 code.

Family_-_free_text.png

Remove family history using the x icon on the right side of the row.

Family_-_delete.png

Add additional notes in the Other Info section.

Family_-_other.png

Added and removed family history will update into the PFSH section once the encounter has been signed.

Social history

Information in the Social History plugin will automatically pull from the information in the PFSH section under Social History.

Click Update on the right side of the plugin heading to re-sync the social history information and pull from the section into the encounter.

Social_-_plain.png

Add smoking status using the + symbol next to the heading. Indicate the status using the dropdown selection and adjust the date columns as appropriate.

Social_-_add.png

Remove smoking status using the x icon on the right side of the row.

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Click the heading for Social History Questionnaire to view and update the details.

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Added, removed, and changed social history will update into the PFSH section once the encounter has been signed.

Current medications

Information in the Current Medications plugin will automatically pull from the information in the Medications section on the Current tab.

Click Update on the right side of the plugin heading to re-sync the medication information and pull from the section into the encounter.

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Add medications using the + symbol next to the heading. Search the medication library to add a patient medication. Indicate the appropriate details using the Dosage, Quantity, Units, Refills, Use Generic, and Start Date columns.

add_med.png

Remove medications using the x icon on the right side of the row.

delete_med.png

Added and removed medications will update into the current medication list once the encounter has been signed.

Allergies

Information in the Allergies plugin will automatically pull from the information in the Allergies section.

Click Update on the right side of the plugin heading to re-sync the allergy list and pull from the section into the encounter.

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Add allergies using the + symbol next to the heading. Search the library of food and drug allergies to add a patient allergy. Add the patient's reaction, the severity, and additional comments and information as needed.

add_allergy.png

Remove allergies using the x icon on the right side of the row.

delete_allergy.png

Added and removed allergies will update into the allergy section once the encounter has been signed.

Immunizations

Information in the Immunizations plugin will automatically pull from the information in the Immunization section.

Click Update on the right side of the plugin heading to re-sync the immunization list and pull from the section into the encounter.

Imm_-_plain.png

Add immunization records using the + symbol next to the heading.

Imm_-_add.png

Search for the immunization from the vaccine database. Enter additional information as appropriate.

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If your practice is set up for immunization registry reporting, you can select Include in Registry to send this immunization record to your state's registry.

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Additional details are required for registry reporting. Complete the additional fields in the pop up and then click Add to Registry.

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Each added immunization record displays in a separate sub-section. Remove immunizations using the x icon on the right side of the sub-section header.

Imm_-_delete.png

Added and removed immunizations will update into the immunization section once the encounter has been signed.

Diagnosis

Information in the Diagnosis plugin will automatically pull from the information in the Problems section.

Click Update on the right side of the plugin heading to re-sync the diagnosis information and pull from the section into the encounter.

Dx_-_plain.png

Add new diagnoses using the + symbol next to the heading.

Dx_-_add.png

In the IMO pop up, search by keyword or description to find ICD-10 codes.

search_IMO.png

Click on the + icon to add a diagnosis to the plugin.

simple_IMO.png

Click on the > icon to narrow down additional diagnosis details.

complex_IMO.png

Select options using the checkbox sections.

mceclip0.png

Choose the appropriate diagnosis using the + icon to add it to the plugin.

__complex_IMO.png

Update the Onset date, Diagnosis date, Status, and other information as needed. Reorder the diagnoses using the up/down arrows.

Dx_-_arrows.png

Remove diagnoses using the x icon on the right side of the row.

Dx_-_delete.png

Added and removed diagnoses will update into the Problem section once the encounter has been signed.

Coding

No information will be populated into the Coding plugin by default, since the coding details are specific to the individual patient encounter.

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Click the + icon to add a procedure code to the plugin.

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Use the search bar to search by CPT code or description and select the appropriate procedure.

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Use the diagnosis option to link a patient diagnosis to the procedure. Diagnosis codes are available from those added in the Diagnosis plugin.

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Use the modifier option to link modifers to the procedure. Modifiers are available from the full list of procedure modifiers.

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Click the + icon to link up to four diagnosis codes and modifiers to the procedure.

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Click the trash icon to unlink a diagnosis code or modifier.

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Add units for the procedure.

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Click Add Advanced Information to add additional line item details.

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Additional fields will show automatically. Place of service and provider options are based on the items set up in the Billing product.

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Only the procedure code is required. Linked diagnosis codes and units are optional. Click Save to add the procedure to the Coding plugin.

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Click the ^ icon to view details linked to a procedure code.

Code_-_expand_icon.png Code_-_expanded.png

Remove procedures using the x icon on the right side of the row.

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 Available starting Tuesday, December 1st

Click the three dots icon to open the action menu.

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Click Edit to make changes to linked information for a procedure.

 

 

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