Visit Note Documentation Guide- Best practices for documenting a patient encounter

Contents

• Why should I document patient encounters in Elation?
• Ways to speed up Visit Note documentation
• Using content from a previously documented encounter
• Using automations to start a visit note draft
• Using templates
  • Visit Note Templates
  • Physical Exam (PE) and Review of Systems (ROS) templates
• Using the Clinical Profile to assist with documentation
• Completing the Visit Note
  • Navigating the Visit Note with your keyboard
  • Recording vitals
  • Addressing Clinical Reminders
  • Taking clinical action with the visit note draft open
• Billing

 


 

Why should I document patient encounters in Elation?

Elation's Visit Note feature offers many structured fields for storing important details regarding a patient encounter. Storing patient encounter details in a structured way allows for better collaboration amongst various providers and organizations that are caring for the same patient. You can easily view visit notes within a patient's chart or share a copy of the structured visit note with any provider or organization. 

 

Ways to speed up Visit Note documentation

There are a few quick ways to speed up Visit Note documentation:

1. For patients who are seeing you for annual exams or chronic conditions follow up you can copy the content from a prior visit note for use in the new Visit Note. This allows you to re-use existing documentation to speed up documentation.
2. For documenting common encounters, we recommend recording the patient's appointment in the Elation Calendar to use our calendar to visit note automation to start your visit note draft. This will allow you to quickly:
   1. specify which Visit Note Format you wish to use to document your encounter and apply the correct format to your documentation
   2. specify which Visit Note Category you wish to use to assign to the encounter
   3. pre-populate important visit note details like the encounter date and time, provider & chief complaint
   4. apply Visit Note Templates to your documentation
3. Use existing Clinical Profile documentation
4. Apply templates to your documentation
5. Take all the actions needed to complete the encounter directly within the visit note draft

 

Using content from a previously documented encounter

You can use any existing completed visit note from the patient's chart to draft a new patient encounter.

• To copy all the contents of a previous visit note, go to the signed visit note that you want to copy and click "Actions" -> "Export to: New Note".
• To copy only the HPI section of of a previous visit note, go to the signed visit note that you want to copy and click "Actions" -> "Export to: New Note (HPI Only)".

 

Using automations to start a visit note draft

The visit note automation features allow you to quickly:

1. specify which Visit Note Format you wish to use to document your encounter and apply the correct format to your documentation
2. specify which Visit Note Category you wish to use to assign to the encounter
3. pre-populate important visit note details like the encounter date and time, provider & chief complaint
4. apply Visit Note Templates to your documentation

Learn more about how to configure and utilize the feature in the Visit Note Documentation Guide- Using visit note automation for appointments article.


 

Using Templates

There are a few template features you can use for any patient encounter. Templates help reduce repetitive documentation for standard evaluations and procedures and allow you to clearly lay out the steps and questions to be addressed during an encounter. 

 

Visit Note Templates

Visit Note Templates encourage consistent workflows across providers and staff by clearly laying out the steps and questions to be addressed. You can:

• Create custom templates that suit your practice needs
• Export templates across all visit note formats 
• Add one or multiple templates to a visit note
• Associate CPT® codes and billing items to templates
• Add POS and billing notes to auto-populate information needed for virtual billing
• Capture document tags to assist with reporting

 

To apply a Visit Note Template to your visit note draft:

1. Open the "Visit Note Template" management window by using one of the following options:
   1. Click on the "Templates" icon in a patient's chart & select "Visit Note Templates" from the dropdown menu
   2. Click on the "Visit Note Templates" button at the top left-hand corner of the visit note
2. Select one or more checkboxes next to the template(s) of interest OR click the "Export" button next to a template
3. Click the "Export All Selected to Note" button

 

Learn more about creating Visit Notes Templates in the Visit Note Templates Guide.

 

Physical Exam (PE) & Review of Systems (ROS) templates

PE (Physical Exam) Templates are pre-created texts of the evaluations of a patient's physical appearance divided by their anatomy. To apply a PE Template to a visit note, click the "PE Templates" button and select a template.

ROS (Review of Systems) Templates are pre-created texts of the evaluations of a patients' various organ systems. To apply a ROS Template to a visit note, click the "ROS Templates" button and select a template.

PE Templates and ROS Templates come in handy for inserting standard evaluations based on the patient's exam reason. This way providers only need to edit the evaluations that are different from the standard or normal evaluations. Learn more about PE and ROS Templates in the Visit Note Documentation Guide- Physical Exam (PE) & Review of Systems (ROS) Templates article.

 

 

Using the Clinical Profile to assist with documentation

Any record in the clinical profile can be referenced into a note or visit note to facilitate documentation of a clinical encounter. You can click the "Actions" button next to any header to export the entire section to a note or visit note. You can also click "Actions" next to a specific record to only export that record to a note or visit note. Certain visit note formats also allow you to import different sections of the Clinical Profile into your visit note with buttons directly within the visit note format itself. Review the various visit note formats in the Visit Note Documentation Guide- Visit Note Formats article to choose the best format for your charting preferences.

Click here to learn more about using Clinical Profile documentation to facilitate charting.


 

Completing the Visit Note

 

Navigating the Visit Note with your keyboard

You can use your keyboard to help you quickly navigate the visit note and document information in different fields. Here are the various ways:

1. When you type in a text field in the HPI section of the Visit Note (ex. pressure in chest) and you want to add another record to the HPI section, hit the "TAB" key on your keyboard to add the next record (ex. hip pain)
2. When you type in a text field in the HPI section of the Visit Note and you want to add additional sub-text to the record (ex. details about the problem) in a different text box, hit the "ENTER" key on your keyboard to add sub-text.
   • User Tip: This sub-text in a different text box option is only available in the HPI & Assessment sections of the 2 column visit note formats and only available in the Assessment section of the 1 column & Pre-Op visit note formats.
3. If you want to add a line break in the same text box, hold down the “SHIFT” key on your keyboard and press the “ENTER” key on your keyboard.
4. Use the "TAB" key on your keyboard to jump from the text field of one section of the visit note to the text field of the next section of a visit note.
5. You can also use your keyboard to take various actions. Use the "TAB" key on your keyboard to navigate to specific buttons. When an action is highlighted because of the "TAB" key, you will see a blue border behind the button. Afterwards, hit the "ENTER" key on your keyboard to trigger the action. 

 

Recording vitals

The Vitals section of a visit note allows providers/staff to record patient vitals information as applicable for the encounter. We have a couple of automations built into this section to allow for easier and quicker documentation:

1. If the patient's height ("Ht") was ever recorded for the patient in a previous encounter, you only need to type in the patient's weight in the "Wt" field for the new encounter and Elation will automatically use the previously recorded height to calculate the patient's BMI. This is ideal for use when the patient's height does not fluctuate often.
2. You can enter certain vitals information using an alternative measurement system (using the following units) and Elation will automatically convert the measurement to the unit of measurement utilized in Elation.

 

Addressing Clinical Reminders

The Clinical Reminders feature provides notifications at the top of in-draft visit notes to remind providers of certain actions to take to address gaps in patient care based on the patient's demographics and problems. This reduces the need for providers to review the entire chart to find conditions that they need to follow up on. A majority of the Clinical Reminders in Elation are tied to specific Clinical Quality Measures for different government programs that Elation supports. However, the reminders are still applicable for addressing care gaps even if you are not participating in government programs because a majority of the care gaps apply to the general patient population for primary care providers.

Clinical Reminders are generally addressed by providers but we also accommodate for staff users who assist with addressing certain reminders (ex. recording BMI). For this reason, staff and provider Clinical Reminder settings are separated. Each provider chooses which Clinical Reminder they want to utilize under their own Preferences settings and the settings for all the staff in the practice are under Clinical Care Measure Setting. 

Learn more about how to customer Clinical Reminder settings and how to take action on Clinical Reminders in this Clinical Reminders for Clinical Quality Measures article.

• User Tip: There are 28 Clinical Reminders available in Elation and a majority of them are for government programs reporting. If you do not see the full set of Clinical Reminders and wish to utilize them, use the "I need help" >> "I need help from Elation Team Member" button at the top of your Elation account to request access to all the Clinical Reminders available. A member of the Support Team will assist you with this request.

 

Taking clinical actions with the visit note draft open

 
As best practice, when you are taking any actions in the patient's chart while the patient is being seen, keep the in-draft visit note open in the patient's chart. This will automatically:

1. Reference any reports you viewed in the:
   • Documents Referenced section of the Simple Note and SOAP Note formats
   • Data section of all the H&P notes and the Pre-Op Note formats
2. Record any prescriptions, orders or referrals you write for the patient in the:
   • Tests section of the 2-column visit note format
   • Orders section of all other visit note formats
3. Record any vaccinations administered that day in the: 
   • HPI section of the Simple Note format
   • Plan section of the SOAP Note format
   • Assessment/Plan section of the 1 column, 2 col-A/P and Pre-Op Note formats
   • Tx (treatment) section of the 2 column format
4. Record any point-of-care labs entered (if you choose "Sign & Export to Note) in the:
   • HPI section of the Simple Note format
   • Objective section of the SOAP Note format
   • Data section of all other visit note formats
5. Reference any handouts given to the patient in the Care Plan section of all visit note formats

 

Billing

For providers who are submitting claims to payers, make sure you enter the procedures and diagnoses for services rendered along with the place of service information in the Billing Information section at the bottom of the visit note. Certain actions taken from the Problem List of the Clinical Profile or Assessment and Procedures section of the different H&P notes or Pre-Op Note formats will assist you with your coding.

Learn more about how to enter billing information in the Billing Guide- Creating a Super Bill and coding for your visit article.



 

Related Articles

• Visit Note Categories Guide
• Visit Note Documentation Guide- Visit Note Formats
• Visit Note Documentation Guide- Using visit note automation for appointments
• Visit Note Documentation Guide- Physical Exam (PE) & Review of Systems (ROS) Templates
• Visit Note Documentation Guide- Using Clinical Profile documentation to facilitate charting
• Visit Note Templates Guide
• Clinical Reminders for Clinical Quality Measures
• Billing Guide- Creating a superbill & coding for your visit