Module guide · Clinical

Encounters

An encounter is one patient visit, from arrival to discharge. This module is where every visit is opened, tracked, documented, and closed out.

Overview Encounters list My worklist Analytics The encounter Good practices

What this module is for

Every time a patient shows up, calls in, or is admitted, that's an “encounter.” This module tracks it from the moment it's opened through triage, orders, notes, and medications, all the way to discharge.

Who uses it

Admissions clerks and nurses open encounters and move them through triage. Physicians, nurses and therapists chart on them. Care coordinators and case managers work the worklist. Directors and quality/compliance staff use the analytics view.

Where to find it

Open Encounters from the sidebar. Four screens: the full list, your personal worklist, an analytics dashboard, and the encounter record itself.

1
Encounters
The hospital-wide list of every visit, search, filter, start a new one, export a monthly report.
2
My Worklist
A live, real-time to-do board for a department or your own patients, unsigned notes, STAT orders, and other flags at a glance.
3
Encounter Analytics
Volume, length of stay, billing gaps and quality metrics over a date range, for leadership and QA.
4
The encounter itself
13 tabs covering diagnoses, allergies, medications, orders, notes and more, plus the discharge checklist.

Encounters

The hospital-wide list of every visit on record.

Stat tiles

Field	What it means
Total (page)	Encounters on the currently loaded page, not the grand total in the system.
Active	Loaded encounters that aren't Finished, Cancelled, Closed or Entered in Error.
Unsigned Notes	Loaded encounters with at least one clinical note still awaiting a signature.
Pending Orders	Loaded encounters with at least one order still pending.

Search and filters

Field	What it means
Search	Filters live by account number, chief complaint, or provider name.
Status	All Statuses, or one specific encounter status (see the status legend below).
Class	All Classes, or one encounter class, e.g. Ambulatory, Emergency, Inpatient, Observation, Telehealth.

Each row shows account #, patient (with MRN underneath), class, status badge, chief complaint, attending provider, arrival time, length of stay in hours, and flag tags (UNSIGNED, ORDERS) when applicable. Click a row to open the encounter. Export CSV (this month), top right, downloads every encounter from the 1st of the current month to now.

"New Encounter" form

Field	What it means
Patient*	Search and select an existing patient.
Encounter Class*	e.g. Ambulatory, Emergency, Inpatient, Observation, Home Health, Virtual/Telehealth. Defaults to Ambulatory.
Encounter Type	Optional, e.g. Office Visit, Follow-up, New Patient, Telemedicine Video, Pre-Operative.
Encounter Date*	Date and time the visit starts, defaults to now.
Chief Complaint	The reason for the visit, in the patient's or staff's own words.
Attending Provider	Optional free text; shows your own name as a placeholder hint.
Department	Optional free text.
Room	Optional free text.

No dedicated Admit or Transfer button

Admission is implied by choosing an inpatient-style Encounter Class at creation, e.g. Inpatient or Inpatient Acute, there's no separate admit/transfer step in this module.

My Worklist

A real-time triage board, either for a whole department or just your own patients. Nothing loads until you tell it where to look.

Scope

Field	What it means
By Department	Enter a Department ID, e.g. "dept-001".
By My NPI	Enter your 10-digit National Provider Identifier.
Search	Once loaded, filters by patient name, MRN, or chief complaint.

Filter tiles

Field	What it means
All	Every loaded encounter needing attention.
Unsigned Notes	At least one clinical note isn't signed yet.
STAT Orders	At least one order is pending at STAT priority.
High-Alert Meds	An active high-alert medication is on the chart.
Missing Consent	Required consent documentation hasn't been captured.
Pending Discharge	The patient is flagged as waiting to go home.

Each patient card shows name, MRN, chief complaint, room/bed, status, a color-coded NEWS2 early-warning score if available (green low, amber medium, red high), quick vitals (length of stay, attending, heart rate, blood pressure, oxygen saturation, pain score), and colored flag badges including Abnormal Vitals, which doesn't get its own filter tile but still shows on the card. Click a card to open that encounter. This screen is read-only, all charting happens on the encounter itself.

Encounter Analytics

A read-only reporting dashboard for leadership, quality and compliance, volume, billing-readiness, and safety metrics over a date range.

Filters

Field	What it means
From / To	Date range, defaults to the 1st of the current month through now.
Department ID	Optional, narrows every metric below to one department.

Stat tiles

Field	What it means
Total Encounters	Count of encounters in the selected range.
Avg LOS (min)	Average length of stay across those encounters, in minutes.
Discharges	Count of discharges in the range.
Pending STAT Orders	Current snapshot, not limited to the date range.
Uncoded Encounters	Encounters missing diagnosis/billing codes, a revenue-cycle completeness metric, current snapshot.
Consent Compliance Gaps	Encounters missing consent documentation since the "From" date, red if any exist.

Volume by Encounter Class

Horizontal bars, one per class present in the range, e.g. Ambulatory, Emergency, Inpatient, scaled to the largest category.

Top Diagnoses

The 10 most common ICD-10 diagnosis codes in the period, with description and count.

Discharges by Disposition

A tile grid of discharge destinations, e.g. Home, SNF, Expired, and how many discharges went to each.

The encounter

Clicking any encounter opens its full record, 13 tabs, status-driven action buttons, and the discharge process.

Only the next valid action is shown

The header buttons change with status: Mark Arrived (Planned), Triage (Arrived), Begin (Provider Seen) (Arrived/Triaged). Cancel is available almost any time before completion and asks for a reason. Discharge happens from its own tab, not a header button. Several confirmations here use plain browser pop-ups rather than in-app dialogs, e.g. Cancel's reason prompt.

Overview

Read-only summary: class, type, department, room/bed, attending, arrival/triage/provider-seen times, length of stay. A SOAP panel (Subjective, Objective, Assessment, Plan). Quality flags: consent not obtained, HIPAA not acknowledged, VTE prophylaxis given, sepsis screen done, fall-risk and Braden scores. Latest vitals if recorded.

Diagnoses (ICD-10-CM)

Add Diagnosis: ICD-10 code and description are required; role (Admitting, Discharge, Chief Complaint, Comorbidity, Pre-/Post-Op, Billing) defaults to Admitting; a chronic-condition checkbox. Remove asks for confirmation.

Allergies

Shows allergies from every encounter this patient has ever had, not just this visit. Add Allergy: allergen (or check NKDA, no known drug allergies), type, reaction, severity (Mild to Life-Threatening, defaults Moderate).

Medications

Medication reconciliation. Add Medication: drug name required, dose, unit, route, frequency, PRN/high-alert/controlled-substance checkboxes. Each drug can be Administered or Refused (reason prompted).

Orders

Visit-scoped orders, separate from CPOE orders elsewhere in the chart. New Order: type (Laboratory, Imaging, Medication, Procedure...), priority (Routine to STAT), description required. Cancel available unless already completed/cancelled.

Notes

New Note: type (Progress Note, SOAP Note, Discharge Summary, and 18 others) and content required. Unsigned notes show a Sign Note button, prompts for your NPI.

Immunizations

Administer Vaccine: vaccine name and CVX code required. Shows dose number, who gave it, and whether it was submitted to the state immunization registry (IIS).

Procedures (CPT/HCPCS)

Add Procedure: CPT code and description required. Shows performer, date, and any complications, highlighted in red.

Care Team

Add Member: provider name required, a checkbox marks them primary. Remove any time.

Referrals

New Referral: reason required, referred-to provider, specialty, and urgency (defaults Routine).

Documents

Upload a file with a title (defaults to the file name) and type (defaults to CLINICAL). Confidential documents get a red badge. Download or Remove any file, removal asks for confirmation.

Status History

Read-only timeline of every status change, from, to, when, by whom, and any reason given.

Discharge — readiness checklist and the discharge action

A 10-item checklist (all orders complete, all notes signed, discharge summary and instructions done, follow-up scheduled, medications reconciled, consent documented, insurance verified, disposition set, transport arranged) shows a check or a circle for each item, and lists outstanding ones.

Discharge Patient: pick a disposition (Home, Home with Home Health, SNF, Hospice, Against Medical Advice, Expired, and others, defaults Home) and optional discharge instructions, then discharge.

The checklist warns, it doesn't block

If items are still outstanding, the page warns that proceeding will discharge anyway if clinically appropriate, it does not stop you from clicking Discharge Patient. Use the checklist as a prompt, not a hard gate.

Planned — scheduled, patient not yet here

Arrived — patient has checked in

Triaged — initial assessment complete

In Progress — provider is actively seeing the patient

On Leave — temporarily away, e.g. for a procedure

Finished — visit complete, patient discharged

Cancelled — the visit was called off

Pending Discharge — waiting on final discharge steps

Good practices

Let the status drive the buttons

The header only shows the one action valid right now, follow it in order (Arrived → Triage → Begin) rather than trying to skip steps.

Worklist needs a department or NPI first

Unlike the main Encounters list, My Worklist shows nothing until you enter a Department ID or your own NPI, there's no "show everything" option by design.

Discharge doesn't hard-block on the checklist

A patient can be discharged with outstanding checklist items, use clinical judgment; don't rely on the checklist alone to catch missing documentation.

Back to all guides Book a live demo