In an Electronic Health Record (EHR), the Patient Encounter section should capture all relevant details of a patient’s visit or interaction with healthcare services. This documentation ensures continuity of care, facilitates effective treatment, and supports accurate billing and administrative processes. Here’s what should be included:

Patient Information

• Patient ID: Unique identifier for the patient.
• Date and Time: The date and time of the encounter.
• Location: The location where the encounter took place (e.g., clinic, hospital, virtual visit).

Reason for Visit

• Chief Complaint: The primary reason the patient sought care, usually described in the patient’s own words.
• History of Present Illness (HPI): Detailed description of the symptoms or issues leading to the visit, including onset, duration, severity, and any factors that improve or worsen the condition.

Subjective Information

• Review of Systems (ROS): Patient-reported symptoms organized by body systems, which may not be directly related to the chief complaint but are relevant for comprehensive evaluation.
• Patient History: Relevant aspects of the patient’s medical, family, and social history that pertain to the current encounter.

Objective Information

• Vital Signs: Measurements including blood pressure, heart rate, respiratory rate, temperature, and weight.
• Physical Examination Findings: Observations and results from the physical examination, including inspection, palpation, percussion, and auscultation findings.
• Diagnostic Results: Results from any tests, imaging studies, or procedures performed during the visit.

Assessment

• Diagnosis: The clinical diagnosis or diagnoses made during the encounter.
• Differential Diagnosis: Alternative diagnoses considered, if applicable.
• Clinical Impressions: Summary of the healthcare provider’s evaluation and understanding of the patient’s condition.

Plan

• Treatment Plan: Recommendations for managing the patient’s condition, including medications, therapies, lifestyle changes, or further diagnostic testing.
• Follow-Up: Plans for follow-up appointments, additional tests, referrals to specialists, or other actions required.
• Patient Education: Information provided to the patient about their condition, treatment options, and self-care instructions.

Patient Interaction

• Patient Communication: Notes on discussions with the patient about their condition, treatment options, and any concerns they raised.
• Consent: Documentation of consent obtained for any procedures or treatments.

Administrative Details

• Provider Information: The name and credentials of the healthcare provider conducting the encounter.
• Billing Codes: Appropriate codes for the services provided, if relevant for billing purposes.

Follow-Up Actions

• Action Items: Specific tasks or actions agreed upon during the encounter, including patient responsibilities and provider follow-ups.
• Referrals: Details of any referrals to other healthcare providers or specialists, including the reason for the referral.

Additional Notes

• Special Observations: Any additional observations or notes relevant to the patient’s care that are not covered in the standard categories.

Including these elements ensures that the patient encounter documentation is comprehensive and supports effective care delivery, communication, and coordination among healthcare providers.

Mental Health & Substance Use Disorder (SUD) Encounter Considerations

For mental health or substance use disorder (SUD) encounters, the documentation should be particularly thorough due to the complexity of these conditions. In addition to the standard elements of a patient encounter, include the following specific details:

Subjective Information

• Mental Health History: Detailed account of the patient’s psychiatric history, including past diagnoses, treatments, and hospitalizations.
• Substance Use History: Comprehensive history of substance use, including types of substances used, frequency, duration, and any previous treatments.
• Current Symptoms: Detailed description of current mental health symptoms or substance use issues, including onset, duration, severity, and any impact on daily functioning.

Objective Information

• Mental Status Examination (MSE): Documentation of the patient’s appearance, behavior, mood, affect, thought processes, cognition, and insight. This should include assessments of:
  • Appearance and Behavior: Patient’s demeanor, dress, and behavior during the encounter.
  • Mood and Affect: Patient’s emotional state and its congruence with their expressed thoughts.
  • Thought Processes: Patterns of thinking, coherence, and logic.
  • Thought Content: Presence of any delusions, hallucinations, or suicidal/homicidal ideation.
  • Cognition: Awareness, attention, memory, and orientation.
  • Insight and Judgment: Patient’s understanding of their condition and ability to make reasoned decisions.

Assessment

• Psychiatric Diagnosis: Specific mental health diagnoses using DSM-5 or ICD-10 codes.
• Severity and Risk Assessment: Evaluation of the severity of symptoms and any associated risks, such as suicidal ideation or self-harm.
• Substance Use Assessment: Evaluation of the extent and impact of substance use, including any withdrawal symptoms or cravings.

Plan

• Treatment Goals: Specific goals for mental health or SUD treatment, including short-term and long-term objectives.
• Therapeutic Interventions: Details of any planned or ongoing therapies, such as cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT), or other evidence-based practices.
• Medication Management: Documentation of medications prescribed for mental health or SUD, including dosage, administration, and monitoring for side effects.
• Referral and Support Services: Information on referrals to specialized mental health or addiction services, including counseling, support groups, or residential treatment programs.
• Safety Planning: Creation of a safety plan if there is a risk of self-harm or harm to others, including emergency contacts and strategies for crisis situations.

Patient Engagement

• Treatment Preferences: Documentation of the patient’s preferences for treatment approaches and their involvement in the decision-making process.
• Motivation and Readiness: Assessment of the patient’s motivation for change and readiness to engage in treatment for mental health or substance use issues.

Follow-Up and Monitoring

• Progress Monitoring: Plans for ongoing monitoring of mental health or substance use symptoms, including follow-up appointments and assessment intervals.
• Outcome Measures: Use of standardized tools to track progress and outcomes, such as depression scales or substance use inventories.

Collaboration and Coordination

• Care Team Communication: Notes on coordination with other healthcare providers involved in the patient’s care, including primary care physicians, specialists, and case managers.
• Family Involvement: If appropriate and with patient consent, documentation of family or caregiver involvement in the treatment process.

Legal and Ethical Considerations

• Consent for Treatment: Documentation of informed consent for mental health or SUD treatments, including any consent for sharing information with other providers or agencies.
• Confidentiality: Notes on measures taken to ensure confidentiality and privacy of the patient’s mental health or substance use information.

Including these additional elements ensures that the documentation for mental health and SUD encounters is comprehensive, sensitive to the complexities of these conditions, and supportive of effective care and treatment planning.