Documenting Patient Encounters and Consultations
Last updated August 27, 2024
Accurate and thorough documentation of patient encounters and consultations is fundamental to providing effective healthcare. PatientEdge offers a streamlined system for capturing and organizing this critical information, ensuring clear communication, continuity of care, and legal protection for your practice.
Recording Patient Encounters
- Access the Patient Chart: After each appointment, access the patient's electronic chart within PatientEdge to document the encounter.
- Specify Encounter Type: Indicate the type of encounter, such as a routine checkup, follow-up visit, consultation, or emergency visit.
- Record Presenting Complaint: Document the patient's primary reason for seeking medical attention, including their symptoms and concerns.
Detailing the Examination
- Document Findings: Record your examination findings, including vital signs, physical exam results, and relevant observations.
- Capture Patient History: Review and update the patient's medical history, including any significant changes or new information relevant to the encounter.
- Assess Diagnostic Tests: Indicate the results of any diagnostic tests ordered during the encounter, including lab tests, imaging scans, or other evaluations.
Developing the Treatment Plan
- Outline the Treatment Plan: Document your recommended treatment plan, including medications prescribed, therapies recommended, follow-up instructions, or referrals to specialists.
- Discuss Patient Preferences: Record any patient questions, concerns, or preferences regarding the treatment plan, ensuring informed consent and shared decision-making.
- Document Patient Education: Record any patient education provided during the encounter, such as information about their condition, medication instructions, or self-care advice.
Additional Documentation
- Attaching Supporting Documents: Upload relevant documents to the patient chart, such as lab results, imaging reports, or referral letters.
- Updating Medications: Ensure the patient's medication list is current and accurate, reflecting any changes or additions made during the encounter.
- Marking Encounters Complete: Complete the documentation process by marking the encounter as finished, ensuring all necessary information has been captured.
Streamlining Clinical Workflows
PatientEdge's electronic charting system facilitates efficient documentation, eliminates the need for paper records, and allows for standardized note templates, improving documentation accuracy and consistency.
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