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  • CPRS - Completing the Encounter Form
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When you attempt to sign your note, the encounter form should appear before you can sign.
  • The Encounter Form is the VA's billing sheet.
  • The key information needed is:
    • The type of visit.
    • The complexity level of the visit.
    • The diagnosis.

No encounter form?

If the encounter form does not appear when trying to sign the note, go back to the Selecting the Correct Encounter.


Follow these steps to correctly fill out the encounter form:

Step

Instructions

Screenshot

Is the encounter form correct?

Check to make sure that the encounter location and date appear in the blue bar at the top of the encounter form window. If this information is incorrect, you will not be able to change it without starting your note all over. Use Tools Feedback to notify CPRS that the Encounter Title/Date should be changed.

Visit Type Tab - "Type of Visit" box

Select the appropriate choice:

  • For clinic visits or ER/Urgent care consultations choose from New Patient, Established, or Consultation.
  • For inpatients choose from Initial Hospital Care, Subsequent Hospital Care, Inpatient Consultation, or Critical Care/ICU.

Visit Type Tab - "Section Name" box

Select the appropriate level of complexity for the visit/encounter.

Visit Type Tab - "Current Providers for this Encounter" box

  • Add the appropriate providers involved with the patient's care.
  • If you are a resident who saw the patient and is writing the note, there should be at least 2 names in this box:
    1. Your name.
    2. Your attending. THE ATTENDING IS THE PRIMARY PROVIDER!!!

Visit Type Tab - "Visit Related to" box

Check "yes" for all the conditions that apply to the diagnosis for which the patient is being seen. For example, if the condition is a service connected condition, select "yes" for the service connected option.

Diagnosis Tab

  • Enter all primary and secondary diagnoses for the visit.
  • If entering more than one diagnosis, select the primary diagnosis and click the "Primary" button.
  • If one or more of the diagnosis needs to be added to the patient's running problem list, select the diagnosis and then click the "Add to Problem List" check box.
  • There are 2 ways to find diagnoses:
  1. Select from choices in the "Diagnosis Section" box at the upper left hand corner of the enounter form.
    • Diagnoses previously entered into the patient's record will appear under the "Problem List Items" option.
    • Some standard neurological diagnosis are under their respective categories list below that.
    • Clicking on a choice in the "Diagnoses Section" box will bring up a list of diagnoses in the "Section Name" box to the right.
  2. Click on the "Other Diagnosis..." button and search for the diagnosis if you could not find it in the "Diagnoses Section" lists.

Procedures Tab

If you performed a procedure (e.g. a lumbar puncture), select the procedure you performed.




Done with the Encounter Form?

  1. Click "OK".
  2. Sign your note.



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