Completing an Encounter Form

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  • Encounter Forms are used to create clinical notes and assessments.
  • Once an Encounter Form has been initiated, a set of boxes that correspond to sections of the form will appear. These are called Models. The complete section name for each button will appear as you roll over each box with your cursor (i.e., Dx = Diagnosis). These boxes and their corresponding text links will appear in gray, green, or red, according to their status:
Gray = Completed Section
Green = Requires completion before signing note
Red = completion not required, but available for filling out or modifying.
  • Clicking the model button or its corresponding text header will take you to that model.
  • Fill out the model by either clicking on the appropriate boxes or typing in the open fields as necessary.
  • When you have completed the model, click on the Update [Name of Model] button.
    • Note: You must click the Update [Name of Model] button in order to leave this section of the form.
  • Once you have completed all the required or necessary models within this Encounter Form, click on the Signature button to sign the form.
    • If the required sections of the Encounter Form have not been completed, you will be prompted to return to the form to finish editing it.
    • Once a form is signed, it is locked from further editing unless your notes require a counter-signature by a Supervisor. Forms that require a Supervisor’s signature can be unsigned by the Supervisor, who can edit the form themselves or send the unsigned form back to you for editing and resigning.
  • You can exit a form before it is completed and signed at any time. All data will be saved, even without a signature.
    • To return to that unfinished note, roll over the Tasks tab, then click on Unfinished Notes. You will see a list of clients and the notes that are unfinished for each. Click on the text link for the note you wish to complete.

NOTE: On the Superbill model of the form, this model requires you to choose a CPT or billing code that is acceptable for that Encounter Form. An acceptable Axis I Diagnosis is also required to complete the Superbill model.