TORCH: Patient Encounters - How To

When the patient record opens, click the Encounters button from the top menu.

In the bottom left frame click the New Encounter button. This will open a new fullscreen (in most browsers) Encounter screen.

This screen is divided into three sections. Along the top is the Encounter Menu, down the left side is the frame where most selections will appear. The right-hand frame usually contains the areas to be edited or previously closed sections to be displayed.

You should now have Template Divisions in the left frame and a blank Encounter form in the right frame.

The blank form consists of the following parts:

1. ICD9 Lookup button - can be used to find a diagnosis code while completing the encounter if desired. Usually these are already embedded into the diagnosis templates.

2. Timer - stores the length of time in seconds that the encounter note is open. Could be useful in E&M Coding. It can be reset back to zero if needed.

3. Restricted Access checkbox - Restricts access to this encounter to only being opened by the current provider.

4. Encounter Type and Level selections.

5. Location - select the proper location of this encounter.

6. Height & Weight at this time. The current height & weight should be entered in the basic information section of the EHR at each visit. It can be reentered here or automatically entered by a template action such as the BMI Calculation (see Routine Exam).

7. Free text vital sign entries - Local policy must dictate the conditions and postures for these measurements.

8. PMH - Past Medical History form.

9. ROS - Review of Systems.

10. Family - Family medical history.

11. Social - Social History.

12. Complaint - the patient's chief complaint for this encounter.

13. History - Combination of template text and free text with HTML markup as appropriate.

14. Physical Exam - Combination of template text and free text with HTML markup as appropriate.

15. Tests - Combination of template text and free text with HTML markup as appropriate.

16. Diagnosis - Combination of template text and free text with HTML markup as appropriate. If capturing the diagnosis for the patient problem list is a desired effect then the ICD codes must be contained in markup tags, ie.
'197.25'

17. Treatment - Combination of template text and free text with HTML markup as appropriate.

18. The Save button - (obviously?) Saves the Encounter. You may Save and edit the Encounter as often as you wish. When you have saved it the first time it will be displayed above the text boxes for you to review the rendered version while editing.

19. The Clear Note button - completely erases everything you have enterd into this Encounter.

20. The current provider should be selected in the pulldown but you may change it to another if required.

21. Once in edit mode there is an additonal notes box that is there for comments that may be made by a reviewing provider. This provider would then perform the sign-off function and the encounter note cannot be changed.

22. Print Note button - This button creates a PDF of the note and in a browser configured correctly will return that PDF. This note can then be printed or saved to a local disk if desired.

Each of the above text sections also have a spellcheck button that will execute ispell. A medical dictionary has not been included but can be created from the text you enter.