Patient Encounters: Difference between revisions

Latest revision as of 16:07, 20 June 2025

Clinical Documentation

VEHRDICT makes clinical documentation faster, more accurate, and more efficient. With advanced dictation and speech recognition technology, providers can transcribe encounter notes simply by speaking. This hands-free approach minimizes errors and saves time. AI-enhanced features organize and analyze data intelligently, ensuring comprehensive and compliant records — allowing you to focus more on care and less on paperwork.

**Encounter List** – View and manage past clinical visits.

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Documentation Overview

Every patient visit is automatically logged and displayed in a structured format.
Each encounter captures:

 * Appointment details
 * Vitals, immunizations, and prescriptions
 * External procedures
 * Billing and diagnosis codes

VEHRDICT integrates seamlessly with dictation and transcription — all documentation appears directly within the patient chart.

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Starting an Encounter

Tutorial Video – Starting a new patient encounter step-by-step.

Option 1: From the Patient Dashboard

Open the Patient Dashboard for the appropriate patient.
Select Appointments from the top menu.
Click an existing appointment or create a new one.
Click the appointment, then select Start Encounter from the menu.

Option 2: From Appointments View

Click Appointments in the left sidebar.
Choose an appointment from the calendar.
Click Start Encounter.

Option 3: From the Encounters Tab

Navigate to Patient > Encounters.
Click Add New.
Enter encounter details and click Save.
This method can be used to start encounters manually without using the appointment module.

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Viewing and Managing Encounters

Encounter List

View all visits recorded for a patient.
Entries are sorted chronologically, with newest at the bottom.
Each item includes:

 * Date/time
 * Visit type
 * Provider
 * Notes
 * Linked documents (e.g., transcription, H&P)

Timeline Chart

Displays encounters in a scrollable visual timeline.
Simplifies navigation through a patient's clinical history.
Supports fast access to diagnoses, services rendered, and billing codes.

Adding Encounter Data

From the patient’s dashboard, click the Encounters tab.
Select an encounter or click Add New.
You may enter data manually or:

 * Use the microphone icon to dictate a new entry via VEHRDICT AI.
 * Use quick-action buttons in the top-right for adding vitals, diagnoses, prescriptions, and more.

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By utilizing VEHRDICT’s smart encounter tools and voice-powered documentation, providers can streamline their workflow, reduce documentation time, and ensure every encounter is accurately captured in the patient's chart.

@@ Line 1: / Line 1: @@
-VEHRDICT makes clinical documentation faster, more accurate, and incredibly efficient. With our state-of-the-art dictation and speech recognition technology, healthcare providers can effortlessly transcribe and manage encounter notes and clinical data by simply speaking. This hands-free approach not only saves valuable time but also reduces the common errors associated with manual data entry. Our AI-enhanced features further streamline the process by intelligently organizing and analyzing the captured data, ensuring that every piece of information is correctly placed within the patient’s record. With VEHRDICT, you can trust that your clinical documentation will be comprehensive, compliant, and up to date, freeing you to focus more on patient care and less on paperwork.
+== Clinical Documentation ==
+'''VEHRDICT''' makes clinical documentation faster, more accurate, and more efficient. With advanced dictation and speech recognition technology, providers can transcribe encounter notes simply by speaking. This hands-free approach minimizes errors and saves time. AI-enhanced features organize and analyze data intelligently, ensuring comprehensive and compliant records — allowing you to focus more on care and less on paperwork.
-[[File:PatientDashboard_EncountersList.jpg|800px]]
+<div style="text-align:center; margin: 1em 0;">
+[[File:encounter_list_nx.jpg|thumb|center|600px|'''Encounter List''' – View and manage past clinical visits.]]
+</div>
+---
-All information related to a patient visit is intuitively documented in Vehrdict EHR. From the time a patient appointment is created until the time the patient completes the visit or call, all information is stored for the encounter. All information about immunizations, vitals, external procedures, and prescriptions are documented. Vehrdict EHR seamlessly integrates with dictation and medical transcription so that all documents appear in the patient’s chart for each encounter. Vehrdict displays each patient encounter in a timeline chart that is intuitive and easy-to-read. All diagnoses and billing information are clearly presented within the encounter so that invoicing and billing are complete and efficient.
+== Documentation Overview ==
+* Every patient visit is automatically logged and displayed in a structured format.
+* Each encounter captures:
+  * Appointment details
+  * Vitals, immunizations, and prescriptions
+  * External procedures
+  * Billing and diagnosis codes
+* VEHRDICT integrates seamlessly with dictation and transcription — all documentation appears directly within the patient chart.
-[[File:clinical_documentation.mp4|800px]]
+---
+== Starting an Encounter ==
+<div style="text-align:center; margin: 1.5em 0;">
+[[File:VEHRDICT-HowTo-Encounter_-_4K.mov|thumb|center|700px|'''Tutorial Video''' – Starting a new patient encounter step-by-step.]]
+</div>
+=== Option 1: From the Patient Dashboard ===
-== Starting an Encounter ==
+# Open the '''Patient Dashboard''' for the appropriate patient.
+# Select '''Appointments''' from the top menu.
+# Click an existing appointment or create a new one.
+# Click the appointment, then select '''Start Encounter''' from the menu.
-To start an encounter, follow these steps:
+=== Option 2: From Appointments View ===
-Navigate to the Patient Dashboard. This can be done by searching for the patient under the search tab. Click on the patient, then at the top of the screen click '''Appointments'''
+# Click '''Appointments''' in the left sidebar.
+# Choose an appointment from the calendar.
+# Click '''Start Encounter'''.
+=== Option 3: From the Encounters Tab ===
-=== Create an Encounter ===
+# Navigate to '''Patient > Encounters'''.
+# Click '''Add New'''.
+# Enter encounter details and click '''Save'''.
+# This method can be used to start encounters manually without using the appointment module.
-# '''Navigate to the Patient Dashboard''':
+---
-## This can be done by searching for the patient under the search tab.
-## Click on the patient, then at the top of the screen click '''Appointments'''.
-## Click on the appointment scheduled and click the '''Start Encounter''' button in the top menu bar.
-# '''Alternatively, start from Appointments''':
-## Go to '''Appointments''' where you'll see a list of all scheduled appointments.
-## Click on an appointment and then click '''Start Encounter'''.
-# '''Create an Encounter''':
-## Click on '''Patient > Encounters'''.
-## Select '''Add New''' to create the new encounter.
-## Enter information regarding the encounter then click '''Save'''.
 == Viewing and Managing Encounters ==
-# '''Encounter List''':
+=== Encounter List ===
-## All information related to a patient visit is intuitively documented.
-## From the time a patient appointment is created until the time the patient completes the visit or call, all information is stored for the encounter.
+* View all visits recorded for a patient.
-## Immunizations, vitals, external procedures, and prescriptions are documented.
+* Entries are sorted chronologically, with newest at the bottom.
-## The system integrates with dictation and medical transcription, so all documents appear in the patient’s chart for each encounter.
+* Each item includes:
-# '''Timeline Chart''':
+  * Date/time
-## Vehrdict displays each patient encounter in a timeline chart that is intuitive and easy-to-read.
+  * Visit type
-## All diagnoses and billing information are clearly presented within the encounter, ensuring that invoicing and billing are complete and efficient.
+  * Provider
-# '''Adding Encounter Data''':
+  * Notes
-## Navigate to the dashboard of the patient, select the encounters tab, and either add a new encounter or select one from the encounter list.
+  * Linked documents (e.g., transcription, H&P)
-## The encounter list displays all encounters in chronological order, with the newest encounters populating at the bottom.
-## To add a new data point to the encounters list, select from the menu options in the top right corner of the page or click the microphone icon and have Vehrdict AI create a new encounter for you.
+=== Timeline Chart ===
+* Displays encounters in a scrollable visual timeline.
+* Simplifies navigation through a patient's clinical history.
+* Supports fast access to diagnoses, services rendered, and billing codes.
+=== Adding Encounter Data ===
+# From the patient’s dashboard, click the '''Encounters''' tab.
+# Select an encounter or click '''Add New'''.
+# You may enter data manually or:
+  * Use the microphone icon to dictate a new entry via VEHRDICT AI.
+  * Use quick-action buttons in the top-right for adding vitals, diagnoses, prescriptions, and more.
+---
+By utilizing VEHRDICT’s smart encounter tools and voice-powered documentation, providers can streamline their workflow, reduce documentation time, and ensure every encounter is accurately captured in the patient's chart.