Retroactive data entry

Management and Administration
1

blatta wrote on Wednesday, February 17, 2016:

Sometimes (rarely) I may see a patient out of the office (in the hospital or outpatient surgery center, for example) and neglect to enter the proper visit-related documentation on the same day. It happened just yesterday as I was at a surgery center that did not have good wireless connectivity back to my home base. Unfortunately, when I returned to the office I forgot to complete documentation for the visit (i.e., “dictate” an op report into the EMR - but it just as well could have been an ER visit, for example). The visit itself is in the calendar, as expected - as it had been previously scheduled - but I can’t document the substance of the visit. Normally if I mark the patient’s status as “arrived” (done at the actual time of the visit) it opens up the functionality wherein I now have access to the clinical documentation portion of the software (SOAP notes, visit-related notes and so forth). This time, however, apparently because the basic “paperwork” of marking the patient “arrived” didn’t actually happen until the next day, I can’t find the encounter in the encounter drop-down box and therefore can’t enter a proper clinical note. Any solutions or workarounds?

2

epsdky wrote on Wednesday, February 17, 2016:

Hello David,

Try creating a new encounter setting “Date of Service:” to the date required.

(Changing the status of an appointment that has expired does no seem to create an encounter)

Regards,

epsdky.

3

blatta wrote on Thursday, February 18, 2016:

My bad. It appears that an appointment had been set on the calendar but no “new encounter” had been opened. As such, I didn’t have access to the functionality usually associated with an encounter. Easy solution. I’ve been using this thing for a year and that’s the first real issue I’ve had. Not much of an issue, I’d say.