Entering Encounter Form Data - Health Factors

To receive workload credit, you enter encounter form data when you create a new Progress Note, completing a consult, or writing a discharge summary for the selected patient.

Note: Once a note, summary, or consult has been completed, you can only change encounter information directly through PCE.

When you select an item from the Health Factors Section list box on the left side of the tab, specific items are displayed in the Section Name list box on the right. The results of your selections are displayed in the list box at the bottom of the tab.

To enter encounter form data on the Health Factors tab, follow these steps:

1. Select the appropriate tab: Notes, Consults, or D/C Summ.

2. Select New Note, New Summary or select Action | Consult Results....

3. Select Encounter.

4. Select the Health Factors tab.

5. Select the appropriate category in the Health Factors Section list box on the left. If no Health Factors are listed, select on the Other Health Factors button to search a comprehensive three-way search for of health factors.

Note: To select other health factors, you may (a) type in the first few letters of the health factor in the search field at the top of the dialog and the program will search for the closest match, (b) scroll through the alphabetic list of health factors in the second field until you find the desired health factor, or (c) select on the expand buttons to reveal health factors grouped by category in the second field. Any time you highlight a health factor in either the second or third field, the program finds and highlights the duplicate entry in the other field.

6. Select on one or more check boxes by the appropriate items in the Section Name list box on the right. The information is automatically added to the Level/Severity-Selected Health Factors field at the bottom of the dialog.

7. Enter any additional information as necessary, such as Level/Severity.

8. When finished, select OK.