Home : Patient Encounter
Patient Encounter

A patient encounter is a record of a patient's arrival in the radiology department for any form of diagnostic and/or therapeutic event. HI-IQ retains permanent records of all patient encounters.

The patient is the highest level of a specificity hierarchy with one-to-many relationships. Each patient can have many encounters (second level), each encounter can have many services (third level), and each service can have many CPTs (fourth level).

When a patient arrives for a diagnostic and/or therapeutic event, it should first be determined whether that patient has a master record on file by using either the Search Options or Advanced Search Options screens (q.v.). If the patient has no master record, one should be created for him/her by selecting "New Patient" from the Patients menu. If the patient does have a master record, it should be selected from the search results window.

To create a new encounter for an existing patient, click the {New Encounter} button on the Patient Information screen. The Patient Encounter screen is opened to a blank encounter record to be filled in.

PATIENT INFORMATION

This section of the screen (top left) displays the patient's ID numbers, name and other information. The patient's age is displayed in spinners; these spinners may be used to modify the patient's age only if the date of birth is not known.

You may specify an ASA code for the patient by selecting from the {ASA Code} menu list, and also describe the patient status by selecting from the {Patient Status} menu list.  This information will automatically default to that patient's most recent previous ASA/Status if the patient has had a previous encounter.

You may enter a Room here if you wish to track the room where the procedure occurred, or if you would like to track the room number of an inpatient.

The {Allergy} button allows you to view and edit the selected patient's allergies.  If the patient has a contrast allergy the Allergy button will be highlighted in red with "Contrast Allergy".

PHYSICIAN / OPERATORS

This section of the screen (top right) is where both the physician/operators and the referring physicians for the encounter are listed. The referring physician(s) from the patient's patient master record are copied to the referring physician list here; clicking the {Referring Physicians} button opens the Referring Physicians Mover screen, where the list may be modified.

There are four categories of physician/operators for patient encounters: Primary, supervisor, 1st assistant and 2nd assistant. Each encounter must have one primary operator. There may also be two supervisors, one 1st assistant and any number of 2nd assistants. The currently defined physician/operators are displayed.

The simplest way to specify a single physician/operator for an encounter is to select from the Phys menu (outside the Encounter window, at the top of the screen), which is only accessible when no physician/operator is listed. You may select one physician as the primary operator. Furthermore, if there is only one physician defined in your system, his/her name is automatically inserted into the physicians list.

To specify more than one physician/operator for the encounter, click the {Physician Operators} button to access the Physician/Operators mover.

ENCOUNTER INFORMATION

This section (middle left) displays information specific to the encounter, including the encounter number and date, the hospital where the encounter occurred, and patient status information.

The small button that is labeled "Encounter" can be clicked and will open a revision history of that encounter.  If this is a new encounter you will receive a message that there is no revision history available.  

The {Appt} button will open the Appointment that the encounter was created from, if one exists.

The {Chart} button allows you to generate the Patient Chart report, for on-screen previewing or printing. The Patient Chart report gives the complete medical history of the patient from all HI - IQ information, listing each encounter, the services performed, the physician/operator(s) and referring physician(s), complications, and notes. Note that this report does not include information for any encounter currently in progress (i.e. newly-created and not yet saved).

The {Day Sheet} button will produce a Day Sheet report for this encounter, when clicked.

When entering a new encounter, the date defaults to the current day, and may be conveniently altered in one-day increments with the up- and down-arrow keys. The {Hospital} defaults to the hospital specified on the patient master record, although you may select any hospital you wish from the list. The {HospID} button allows you to view the patient's hospital identification numbers, for all hospitals defined in your system.

The Entered and Revised area shows the date and user ID of the user who entered and most recently revised this encounter.

Check the {Review} checkbox to mark this case in need of review.

Click the {Emergent} checkbox if the encounter is an emergency. 

Click the {Contrast Reaction} checkbox if a contrast reaction occurred during this Encounter.  This checkbox will automatically be selected if a contrast reaction complication is specified during the Encounter, it will also automatically mark that patient's allergy record with a contrast allergy.

Check the {Interesting} checkbox if you wish to identify the Encounter as "Interesting".  Use the Dashboard filter feature to browse for Interesting cases.

Click the {Data Pending} checkbox to signify that there is data pending from a service on this encounter. This box will be automatically checked if a complication of pending severity or a pending outcome for a performed service is specified in the encounter.

Click on the Nurse/Tech/Scrub/Other buttons to record procedure participants other than physicians.

If you have sound recording capabilities you can attach audio notes to an encounter by clicking on the Audio notes icon.

SERVICES

This section (middle right) lists the services performed for the current encounter; there may be one or several. There are three ways to specify a service to include in the encounter: using the Services menu in the menu bar, clicking the {Services} button to access the Service Tree screen, or by selecting a service package from the Packages menu.

The Services menu contains the entire hierarchy of SIR services, as well as any site-specific customizations. The Service Tree screen allows you to traverse the service hierarchy in a full-screen format. Clicking on a service in the {Services} box causes its full hierarchy to be displayed in the box directly below, i.e. what is listed in the box as "Cerv-Cerebral Ang N.S." would be displayed below as "Arteriography, Diagnostic; Aortography (Non-selective studies); Thoracic; Cervico-Cerebral (1.1.1.1)". To delete a service, select it and click the {Delete} button.

Click the {Services} button to access the Service Tree screen.

Click the Packages button or menu option to view a list of available Packages and to preview their contents.  To select a Package, double-click the name of the Package, or, highlight the name and click the Select button.  If a Package contains multiple ICD9s, you must select one ICD9 before inserting the Package.

Services may only be selected once per encounter.  To indicate a frequency greater than one for a Service, highlight the Service in the selected Services window, increase the frequency in the frequency spinner above and to the right of the selected Services window, and click Apply Freq.

ENCOUNTER NOTES

Finally, any notes you wish to enter about the encounter may be entered in the {Notes} field. This may be "zoomed" to a full text window by clicking the triangular zoom button ^ next to the field. Macros and templates are exposed at this level to allow further conveniences for data entry. Clicking the Macro button shows the macro insertion menu and allows "automatic" entry of this text into the note.

Of particular importance for recordkeeping is the full description of any services with pending data, but you may record any other information you wish that is relevant to the encounter. If you have a standard set of information you wish to record, you may find it useful to define an Encounter Note Template to be filled in; if this template exists, it will be automatically copied into the {Notes} field of all new encounters.

ENCOUNTER TABS

The Patient Encounter screen is also a gateway to other major HI - IQ screens related to the encounter; the ten tabs at the top of the screen allow you to quickly jump among them. A description of each tab follows:

The {Indications} tab opens the Encounter Indications screen, allowing you to describe the patient's indications at the time of the encounter. Separate indications for each service may be listed. If this tab is followed by parentheses and a number, it indicates that the Encounter Indications screen has been used for this encounter and indications have been described.

The {Diags} tab opens the Encounter Diagnoses screen, allowing you to record ICD9 codes for the encounter.  If this tab is followed by parentheses and a number, it indicates that the Encounter Diagnoses screen has been used for this encounter and Diags have been entered.

The {CPT s} tab opens the Encounter CPT code screen, where service- or encounter-specific CPT codes may be specified. Frequency may also be given. If this tab is followed by parentheses and a number, it indicates that CPT codes have been specified for services in this encounter.

The {Inventory} tab allows you to attach product usage to an encounter, if you have purchased a license for HI-IQ's Resource Management module. 

The {Dosages} tab allows you to record a contrast dose, contrast type, radiation dose and Fluoro time for an encounter.  You can also record room time for the procedure on the Dosages tab.

The {Clinical} tab allows you to record clinical details of the encounter, if a Clinical module license has been purchased.  Separate Help Topics exist for screens within the Clinical module.

The {Complications} button opens the Encounter Complications screen, allowing you to describe service- or encounter-specific complications. If this tab is followed by parentheses and a number, it indicates that complications have been listed for this encounter.

The {Outcomes} button opens the Encounter Outcomes screen, allowing you to describe the technical and complication outcomes of this encounter. Success, failure, and outcome pending may be specified for each service, and a notes field is provided.  If this tab is followed by parentheses and a number, it indicates that outcomes have been described for this encounter.

The {Follow-up} tab opens the Follow-up Schedule screen for the patient, allowing the entry of follow-up information and notes.

Click {Save} to accept the encounter screen as it stands, {Cancel} to cancel changes since it was last saved, or {Delete} to delete the entire encounter.

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Created on 2/21/2005.
Last Modified on 11/7/2005.
Last Modified by Kevin Lauzon.
Article has been viewed 16433 times.
Rated 8 out of 10 based on 13 votes.
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