How to Complete Basic Documentation in EHR 24/7

If you're new to using EHR 24/7 or need a refresher on the basic documentation workflow, follow the steps below to access a patient's chart, complete a progress note, and sign off on it.

Before We Begin:

This section is to specifically help with creating Encounters. Templates and uploaded documents can also be used for documentation purposes. We will focus on creating encounters in this article. Before creating an encounter, it's a good idea to make sure that any custom SOAP layouts have been configured under the Manage Office tab in the SOAP Note Layout section.

Understanding Encounters vs. Documents

Encounters are almost always the primary type of object used in EHR 24/7 to document patient interactions. Following the SOAP documentation method, Encounters can be highly customized in terms of quantity and variety of fields available for use, but are restrictive in the format of the resulting document.

Documents in a patient chart are either uploaded files or created from 'Templates' stored in Manage Office. Documents are much more customizable in layout and can be used for a wide range of documentation, but the data entered into a Document is only accessible on the Document -- not elsewhere in the Patient Chart and not included in Reports.

Both Encounters and Documents are critical tools you will use for complete patient documentation.

Accessing the Patient Chart:

If you select the Patient Charts Tab, you can use the search bar at the top to search by last name or other parameters for a patient. From the search results you can click on the patient’s name or the Open Chart icon to access the chart.

The Patient Chart can also be accessed from the other places such as the Desktop tab and appointments.

Steps to Start and Complete an Encounter:

1. Create a New Progress Note

• Hover over Progress Notes in the top menu.

• Under Add Custom Progress Note/Encounter, select the appropriate note template based on your office setup.

2. Set Note Preferences

• In the note settings, at the top portion of the note, adjust settings such as date of service, treating provider, and guideline selections.

3. Review Patient History & Related Documents

• From the left-hand menu, view past notes, nurse notes, documents, and adjust print settings if needed. Information from the previous notes can be copied from here in various places.  

4. Enter Clinical Information

• In the main body of the note, type into the relevant fields configured in your SOAP layout.

• You can also use any guidelines selected earlier to streamline documentation.

5. Add Diagnoses and CPT Codes

• Scroll down to enter relevant ICD and CPT codes for treatment and billing purposes.

6. Save the Note

• Click the Update button at either the top or bottom of the page to save your entries.

7. Review and Finalize

• You will be taken to the View Progress Note page, where you can perform various actions like attach documents, route the note and/or begin the billing process

8. Sign the Note

• At the top of the note, click Sign.

• A warning will appear notifying you that the note will become permanent and cannot be edited.

• Click Sign Off to finalize the documentation.

With the Provider's signature, the note can no longer be edited or deleted.  While you can add addendums or transfer a signed Encounter to another patient chart, it now cannot be deleted from the account.

Other Documentation Options

In addition to SOAP notes, EHR 24/7 allows you to enhance documentation using Document Templates and Uploaded Documents. Documents in a patient chart are either uploaded files or created from 'Templates' stored in Manage Office. Documents are much more customizable in layout and can be used for a wide range of documentation, but the data entered into a Document is only accessible on the Document -- not elsewhere in the Patient Chart and not included in Reports.

Using Document Templates

Document Templates are managed under Manage Office > List Maintenance. You can:

• Submit templates to be added by emailing Support@officeally.com

• Search and import templates from the built-in Template Library.

• Build your own templates within the same section using the available tools or HTML.

To add a template to a chart:

• Hover over Documents in the top menu and select Add Document Templates.

• Or, from the View Progress Note page, hover over Documents above the note and select Add Document.

This opens a categorized list of available templates to select, fill out, and save.

Uploading Documents

You can upload documents directly from your device to the patient chart. Note:

• Each file must be under 4MB.

• You must name the file and choose a category to save it too.  

Ways to upload documents:

• From the Top Menu of the Patient Chart: Hover over Documents > select Upload.

• From the View Progress Note Page: Hover over Documents > select Upload.

• From the Document Center Tab: Hover over Documents > select Upload Document.

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