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An encounter is one visit and its note.

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Before you start

You need a verified MDCN licence and access to the patient. See Getting access to a record.

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Steps

1

Open or start the encounter

Open it from Today or Encounter in the sidebar. A front-desk walk-in, a nurse’s triage or a confirmed booking creates it for you. To start one yourself, open the patient and click Start visit.
2

Write the note

The encounter has tabs: Note, Orders, Meds, Labs, Imaging, Dx, Plan and Sign. Write your SOAP note in Note. It saves as you type.
3

Prescribe and order

Use Meds to prescribe and Labs to order tests. See Prescribing and Lab orders and results.
4

Sign

Open Sign and click Sign & complete. Signing is final. Click Confirm — sign now.

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Correct a signed note

You can’t edit a signed note. You see Already signed — the note is immutable. Instead:
  1. Open the signed encounter. It says This encounter is signed.
  2. Under Addendum, give a short reason and write the correction.
  3. Click File addendum. The original note stays as it was, marked as amended.

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Cancel an unsigned encounter

If the visit didn’t happen, click Cancel encounter before signing. The appointment is cancelled too. A signed encounter can’t be cancelled.

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What you can do here

  • Write, autosave, sign and amend notes.
  • Order tests and prescribe from inside the encounter.
The Dx tab (coded diagnoses) is shown but disabled. Coded content is waiting for clinical sign-off. Write diagnoses in your note for now.

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Common problems