These settings control the appearance, layout, and default behavior related to SOAP/ encounter notes, including encounter summaries and wellness plans.
Note that users can individually customize which chart blocks are expanded and collapsed, and in what order, in the encounter screen. See Customizing your Encounter Screen Layout.
For more information about encounter notes in general, see the Help section on Encounter/SOAP Notes
General
When an appointment is marked as "Checked In" status in the calendar, automatically create an encounter note for that patient with the same title
If you use the Checked In status to mark appointments as checked in on your calendar (which is also triggered if you have patients check in via the Check-in Kiosk), you can set that to automatically pre-create an encounter note in the patient's chart. The encounter note will have the same title as the appointment.
Make it possible to manually assign SOAP note "ownership"
By default, an encounter note is "owned" by the person who created or last edited and saved it. If you need users to be able to task encounter notes over to another person in the clinic, you can use this setting to allow that. Unsigned encounter notes that are "owned" by a specific user show on that user's task list under Open SOAP Notes. More on Encounter Note "Ownership".
Turning on manual SOAP note ownership assignment adds a dropdown menu above the Assessment box in an encounter note for the user to manually select an owner. To appear in that dropdown, users must have "Yes" selected for "Can this user be assigned encounter notes" in their user profile (Admin > Manage > Users).
Pre-populate the encounter note title with the name of the encounter type
By default, the title of a brand new encounter note is blank and would need to be manually added. You can use this setting if you want the encounter type to automatically populate into the encounter title field. If this is turned on, a user that creates an encounter note would first select the encounter type, which would then populate into the encounter title field. Related help on Adding New Encounter Types.
Default encounter note type
Prepopulate the encounter note text area (regardless of encounter type) with the following text
The default text prepends the date-and-time variable. You can edit or replace the text.
Which plan types should have "quick-links" on the plan block header when charting
Chart Parts
Chart Parts are templates that can be used within the body of an encounter note (as well as other text fields in Cerbo). As you type in the encounter note body, Chart Parts with a name or nickname that matches your typed text appear as suggestions at the left of the note. To select and use a suggested Chart Part, you can click on the suggestion with your mouse or (if enabled using the selections below) use the arrow keys on your keyboard. Use the provided settings to choose whether:
- Pressing the up-arrow key on the keyboard should select the top-most suggested Chart Part
- Pressing the down, left, or right arrow keys on the keyboard should navigate to or within the suggested Chart Parts list
Note: you can pull context-specific medication and supplement information into the body of your encounter note by using text variables within a Chart Part template. You can customize how that information is pulled under the System Settings for Prescription Medications, and those for Supplements and Alternate Plan.
Signing a Note
The following settings control what is required to sign a note, email notification to the patient about a new encounter summary on the Portal, and what is shared as part of that Portal encounter summary by default.
A diagnosis should be required before an encounter note may be signed
If this is turned on, there must be at least one diagnosis in the Assessment box of the encounter note before the note may be signed.
A charge should be required before an encounter note may be signed
If this is turned on, there must be at least one charge (even if it is a $0 charge) in the Charges/ Payments box of the encounter note before the note may be signed.
Show the option to send an email notification to the patient when an encounter summary is shared
When the encounter note is signed, the encounter summary is automatically shared with the patient on the Portal (IF that is turned on for the selected encounter type). See Signing Encounter Notes & Sharing the Visit Summary). You can use this setting to turn on/ off the option to send the patient a generic email notification of a new encounter summary in the Portal.
When an encounter note (of a type that generates an encounter summary) is signed, the email notification should by default be...
If the option to send a generic email notification of a new encounter summary is on, using the above setting, you can additionally choose whether that option should default to being checked (on, meaning that the notification is sent) or unchecked.
By default, when signing the encounter note, the option to share the text in the main text area of the encounter note as part of the encounter summary should be set to...
Unless designated otherwise in the encounter signing window, the encounter summary includes only the diagnoses from the Assessment box, and any items from the Plan box of the encounter note. If you often want to share the full text body of the encounter note, or a custom version of the note that you opt to share, you can set the default accordingly to using this setting.
Printable Encounter Summary
In addition to the encounter summary that is generated and shared on the Patient Portal, you can generate a printable encounter summary from the EHR. See Signing Encounter Notes & Sharing the Visit Summary. You can use the settings in this section to customize the appearance of the summary document, and control what specific information is included. Specifically, you can configure:
- Custom instructions/ information to include at the top of ALL printable encounter summaries
- Check the box to include H&P by default - including H&P prefaces the encounter summary with key information from the patient's chart.
- Show the Patient Info section (includes the patient's name, DOB, phone number, address, as well as the date of service, provider, and visit type)
- Include the date that the encounter was signed
- Show assessment/ diagnoses
- Show medication prescriptions
- Show alternate plan items (supplements, IVs, injections, custom recommendations)
- Include "Continue Taking" for any active medications or supplements that were not prescribed at this visit, and "Discontinue" for any that were recently discontinued.
- Show vaccines
- Show orders (labs, imaging, referrals)
- Show upcoming appointments
- And, if appointments are shown, when the patient has an upcoming appt with a resource (rather than a user), the resource name should be listed on the encounter summary with that upcoming appt
- Include details about the note signer (date and name) by the signature
Wellness Plan
These settings control the appearance and contents of a Wellness Plan document. See Wellness Plan and Supplement Plan. You can customize the title of the Wellness Plan document that is saved and shared with the patient. As well as customizing the document tab that Wellness Plans save to. Additionally you can:
- Choose between portrait and landscape orientation.
- Omit the timing grid (dosing per time of day) for supplements and the corresponding key.
- Show supplement timing in a table (similar to the Supplement Plan).
- Get rid of the timing abbreviations (and corresponding key) for supplement dosing timing, instead including that information written-out, e.g., "On Rising" "With Breakfast," etc. for each supplement.
- Add a timing grid for medications, like there is available for supplements (note that the timing grid for medications, if enabled, is only visible/ editable in the Wellness Plan itself, not in the prescribing windows).
- Automatically remove expired medication and supplement prescriptions from the Wellness Plan.