Through Past Encounters

• In the main menu, press the Clinical button. 
• Select the patient from any section of the screen. 
• Then, press the Past Encounters button, located at the top of the screen. 
• On the Past Encounters screen, press the New Clinical Record button.

Through Workflow

• Go to the Workflow screen. 
• Select the patient from the Workflow Items section. 
• Then, press the Add button, located at the end of the selected patient. 
• Or, double click on the selected patient. 

• Foto Perfil: Displays the patient's profile picture.
• Name: (Botón: Información Paciente): Display the patient's name. Click on the information button, located next to the name, to display demographic information. 
• Age: Displays the patient's age. 
• Gender: Displays the patient's gender.
• Record No: Display the patient's record number.
• Link: (Insurances): Click on this link to access the patient's medical plan 
• Last Encounter: Displays the date of the patient's last encounter. 

Buttons

• Settings: Allows to configure the progress note display, according to the user's needs. 

• Deleted Progress Note Forms: Pressing displays the screen to reactivate deleted progress notes.
  

• Send to Billing: Allows to close the progress note and in turn, it is sent to invoicing. There must be a note from the provider at the meeting. 

• If there are two or more suppliers, the following screen appears, to select the provider's meeting for which you want to send the invoice. 

• Documents: When pressed, the Documents screen appears.
  

• Close Encounter: Allows you to close all open progress notes.  

• Print: Displays the Encounter Summary screen. 
  

• Previous: Closes screen. 

• Sticky Notes: Allows you to write one or several notes, among the staff that will be attending the patient. This function is exclusive to the Emergency Room, for the internal use of the clinical staff. These notes will not be included in the progress note. 

• Arrival: Displays the date and time the patient arrived at the emergency room or center.
  
• Duration: Displays the time, which the patient has been in the emergency room or center. 
• Last Location: Displays the last location of the patient, in the center or emergency room. 
• Last Attended By: Displays the provider, who attended the patient, at the facility or emergency room. 
• Reason For Visit: Displays the reason for the patient's visit, in the facility or emergency room. 

Buttons

• Add Clinical Task / Clinical Task: It allows to create the clinical task, for the treatment of the patient, in the center or emergency room.

• Consent Forms / Documents Forms: It allows to work with the documents of the patient's encounter.

• New Prescription: Allows to create patient prescriptions.

• Plan Care / Discharge / Plan Care: Displays the screen to manage the instructions given to the patient at the time of discharge from the center or emergency room. Likewise, the patient's plan summary is displayed.

Patient Dashboard 

Clinical Dashboard

Allergies: Section to register the patient's allergies. The user will be able to observe the active and inactive allergies. 

• When the Record Allergies button is clicked, the following screen will be displayed:  

• By clicking on the Allergies link, the following screen will be displayed: 

• Vital Signs: Section to record, record the patient's vital signs and view the history of the vital signs. If you wish to view only the vital signs of the encounter, select the View Encounter Vitals checkbox. If this option is not selected, the history of the patient's vital signs record will be displayed. 

• By pressing the right mouse button, the user will be able to add the selected record to the progress note, if it is another user who recorded the vitals.
  

• Add Vital Signs: Pressing the Add Vital Signs button will display the following screen. If there was already a vital signs record, the second record will automatically display the patient's weight and height. 
  

• Pain Rating: Pressing the Pain Rating button will display the following screen. Enter the patient's pain rating scale.
  

• By clicking on the Vital Signs link, the following screen will be displayed:  

• Medications: Section to register patient's prescriptions and medications. The user will be able to observe the patient's medications, active, suspended and cancelled. 

• By clicking on the New Prescription button, the following screen will be displayed: 

• By clicking on the Medications link, the following screen will be displayed: 

• Problem List: Section to register new diagnoses to the patient. The user will be able to observe the active, resolved and inactive diagnoses of the patient. 

• When the Add New Dxs button is pressed, the following screen will be displayed:  

• By clicking on the Problem List link, the following screen will be displayed: 
  
• Procedures: Section to record procedures performed on the patient. 

• By clicking on the Add New Procedures button, the following screen will be displayed: 

• By clicking on the Procedures link, the following screen will be displayed: 

• Immunizations: Allows to record, vaccines administered to the patient.

• By clicking on the Add Immunizations button, the following screen will be displayed:
  

• By clicking on the Immunizations link, the following screen will be displayed: 

Clinical Tasks

Actions:

• Mark as Completed (Botón): When pressed, it automatically displays the confirmation message, if you want to mark that the tasks were completed. 
• Print Order Sheets: When pressed, displays the report of the orders sent to the patient, as part of the clinical tasks. 

• Expand/Collapse Sections: Pressing allows you to expand or hide the sections of the clinical tasks.
• Print Pending Tasks: When pressed, displays the report of the patient's clinical tasks. 

• Print Completed Tasks: When pressed, displays the report of the patient's completed clinical tasks.  

• IV Sites: Section to record the serums administered to the patient as part of the treatment. By clicking on the link, the following screen will be displayed:  

• Attach Medications (Enlace): When pressed, it displays the medications, assigned as clinical tasks, to be administered through the serum.

Lab Results 

• View Comparer (Enlace): When pressed, it displays the screen where the clinical staff can compare up to a maximum of 5 laboratory results simultaneously.

Service Summary

• Billable Problem List: Displays the list of diagnoses, which will be billed.
  

• Add Billable Problem List: Allows to register diagnoses, for the summary of the services to be billed for the encounter. 

• Billable Procedures List: Displays the list of procedures, which will be invoiced. 

• Add Billable Procedures List: Allows to register the procedures, for the summary of services, to be invoiced for the encounter. 

Clinical Evaluation 

• Progress Note: It allows the creation of multiple progress notes in a single encounter. You can register the patient's signature, print the progress note, close it or select a previously configured clinical evaluation template in the Settings / Clinical Evaluation Templates Settings section. 

• Add: When pressed, multiple progress notes can be added. These are displayed, according to the configuration, in the Progress Templates Settings screen. 

• Date: Displays the date and time when the clinical evaluation of the patient started. The user will be able to select the time, but will not be able to select future dates. 

• Pt Signature: Allows the patient's signature to be recorded on the progress note.

• Print: Allows to print the progress note.

• Close: Allows to close the progress note. Once Close is pressed, a confirmation message is displayed.. 
  
• Evaluation Templates: Displays the list of previously configured Templates in the Progress Notes Evaluation Templates Settings screen. 

• Print: Allows to print the progress note.
  
  
• Nota de Progreso Cerrada: The user will be able to add an Addendum note, from the Clinical Evaluation section.