OpenEMR: New Encounters and Coding

1. Based on OpenEMR 4.1 Laboratory Informatics Institute January 2014 OpenEMR: New Encounters and Coding

2. OpenEMR: New Encounters and Coding • Opening a new encounter. • Encounter forms. • Using the fee sheet. • Adding prescriptions.

3. OpenEMR: New Encounters and Coding • Patient encounters are primarily handled by providers. • Logging in as a provider shows you only that provider's calendar. • To view another provider's schedule select the desired provider's name from the left. • The bottom window shows notes left by the provider about the encounter/patient.

4. OpenEMR: New Encounters and Coding • To begin the new encounter click on the patient's name in the appointment log. • This will bring up previous encounters, files, etc. related to the patient. • Select History at the top of the summary page. Click edit to enter information that may be incomplete.

5. OpenEMR: New Encounters and Coding • Patient Encounters & Documents page, lists all previous encounters and documents. New patients may have no encounters listed. • Patients that have the @ symbol next to their name have arrived. OpenEMR automatically generates an empty encounter form for such patients.

6. OpenEMR: New Encounters and Coding • Open the new entry and click edit located next to the provider's name. • Create visit can be used to generate an encounter form manually, if need be. • Enter a description of the encounter, remember new patients will not have issues/diagnoses associated with them. • Save your work.

7. OpenEMR: New Encounters and Coding • On the summary page there will be a list of forms associated with the encounter. • Click edit next to the appropriate form to edit the content of that form. • Select SOAP from clinical drop down list to add this form to the encounter. • This form contains subjective and objective records, as well as patient health assessments and suggested treatment plans.

8. OpenEMR: New Encounters and Coding • Enter the appropriate information for the encounter on the SOAP form, and click save. • Return to the encounter summary page. • On the summary page the SOAP form has now been added, and there is a summary of its contents as well. • Next select fee sheet from the administrative drop down menu.

9. OpenEMR: New Encounters and Coding • The fee sheet does not appear in the list of encounter forms. • Enters and modifies billing information found elsewhere. • Customize this to your practice. • Drop down list contains common codes.

10. OpenEMR: New Encounters and Coding • Look for an appropriate code using the search function. • Selecting the desired code from the drop down list, will add it to this encounter. • Justification allows for justification of ICD-9 codes being associated with procedure codes. • Insurance companies require this for payment. • Click justify for the appropriate CPT code. Select the appropriate ICD-9 code and select save.

11. OpenEMR: New Encounters and Coding • Click save. • Click visit history to see the SOAP, fee sheet, and codes associated with the encounter. • To add a prescription click edit next to prescriptions on the patient summary sheet. • Click add

12. OpenEMR: New Encounters and Coding • Fill out the prescription form. • Click here to search, allows you to look for a type of medication. • Select the desired medication from the list. • Select yes when prompted to add this drug to the medication list. • PDF form can be printed, emailed, or faxed.

13. OpenEMR: New Encounters and Coding • Selecting a pharmacy and selecting auto send, will automatically use whichever method was selected when the pharmacy was added. • Clicking print pdf will generate the pdf form to be printed or saved as necessary.