The available sections in an encounter are determined by the encounter type in use.
Preconfigured sections for common components of exams, such as SOAP notes, are available for use in encounter types:
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Intake: Information in this section is automatically populated from the client’s completed self check-in form.
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Vitals: Record the patient’s vitals and view vital measurements from previous encounters.
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Subjective: Record observations that are verbally expressed by the client and not already part of the Intake notes.
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Objective: Record all physical exam observations and measurements.
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Assessment: Record the assessment, diagnoses, and differentials.
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Plan: Record the patient’s treatment plan and recap discussions with the client. You can copy the patient’s medication information from their chart directly into this section.
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Orders: Order products, services, and diagnostics in this section to add to the client’s invoice. Learn more about Orders.
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Problem List: This section displays any information added to the Problem List in the right panel of Patient Chart.
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Complications: Choose preconfigured complications to link to the encounter.
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Discharge: Enter notes to include in the Discharge PDF.
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Attachments: Upload attachments to save to Patient Chart and add to the encounter summary.
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Client Consents: Displays any consent forms shared with the client from this encounter (either from this section or from the Consent Forms tab in the encounter footer).
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Linked Encounters: Link the patient’s other related encounters for easy summarization and invoicing.
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Follow Up: Schedule the patient’s next appointment and/or appointment reminder. You can also create patient tasks in this section.