When an encounter starts, the Current Encounter screen opens and includes a problem field for the REF and clinical notes. It also provides access to the clinical modules used to record information and create scripts and referrals.
Current Encounter screen
When an encounter is started, the Current Encounter section opens and displays the clinical modules menu and an Undefined Problem field.
The modules shown can be configured using the top menu under Tools > My Options > Function Selections.
When the encounter ends, the information recorded is saved in the History View and Summary Views.
Adding an RFE
Ideally, an RFE (reason for encounter) is recorded for every encounter and entered into the field provided.
Coded RFEs
RFE codes provide a way for the practice to use a consistent set of RFEs across all practitioners. Tick the Use Coded RFEs box, start typing the code, and the reason for the encounter will autofill.
To show the Coded RFEs box, select Tools > Global Options > Use Coded RFEs.
Coded RFEs can also be configured to add text to the clinical notes field, for example, a checklist for the condition.
Custom RFEs
You can add your own RFEs under Tools> Clinical Setup > RFE codes. Select Add New then type the Code and Description (which will appear in RFE field) and the Default Notes (which will be automatically added to the clinical notes field below the RFE.
Adding a problem
The tab you enter your REF and clinical notes into will be called Undefined Problem, and this can be updated with a problem definition if you use the optional Problems module to select a condition/diagnosis. If you do use the Problems Module, you can select an Existing or Recent problem, a Problem from the ICPC, or Manually add a problem. You can have multiple Problem tabs, each with its own RFE and clinical notes if there are multiple problems presented. The problem classification will also be added to the Problems tab in Summary Views.
Adding notes
Type your clinical notes into the text section below the RFE. To save time, you can use the Auto Text feature and type in a shorthand term to add a clinical entry or checklist. For example, you could type "sore throat" to add a list of checks to complete. As noted above, you could also use the RFE "sore throat" to add a list of checks to complete.
Enable Auto Text
To view the list of Auto Text shorthands available and to add new ones, open Clinical and select the Tools menu > Clinical WP Setup > Auto Text and use Add New to add the Shorthand and Longhand text.
Updating clinical notes
You can change a clinical encounter's notes up to the end of the day it was created. To do this, start an encounter for the patient and select Continue Encounter from the dialog. You can now update your RFE, clinical notes and information entered.
Clinical modules
Clinical modules become available when the encounter starts and provide specialised ways to add information.
Key clinical modules include: