Encounter Care: Patient Header

  • Updated

The modern patient header is designed with accessibility in mind and offers a comprehensive look at patient information. The sticky header ensures that users working on multiple charts can always see which chart they're in, preventing accidental documentation in the wrong patient’s episode of care. image

You can access the expanded header at any time without losing your place in the chart, since it displays most of the facesheet data, saving you an additional click to the Information tab. 

All header actions are now consolidated under one menu button. 

Header Icons

image

  1. Manage Episode: Opens the Episode of Care Summary window. The Episode of Care Summary is a timeline that tracks the patient’s journey through treatment, from creation to discharge. It helps monitor and understand the patient's progress, showing changes in location, level of care, and programs.
  2. Actions: Opens the Actions menu where you can choose the following options:
    • Add New Document: Add a document using centralized documentation
    • Edit Client: Edit patient information in the facesheet. 
    • Print: Print the current screen view.
    • PDF: Convert the screen view into a PDF. 
    • PDF Package: Create a PDF Package.
    • PDF Casefile: Create a PDF Casefile.
    • Print Wristband: Print a Patient Wristband
    • Transfer Client: Transfer the patient to another location or facility by clicking here then choosing the desired location or facility. 
    • Share Portal Package: If Patient Portal Packages are configured in your instance, they will also appear on this list. 
  1. Expand Header: Click on the arrows to expand the patient header (see the section called Expanded Patient Header below for more information). 

Patient Information

The top left of the patient header shows the following information:A screenshot of a computer Description automatically generated

  1. Patient Profile Picture: Photo taken at the facility or uploaded via the Patient Portal during the intake process. 
  2. Patient Full name: Displays the patient's first, last name, and preferred name. 
  3. MR number: Medical record number assigned by the system through the admission workflow.
  4. Allergies: Lists patient allergies, including drug, food, or environmental. 
  5. Pronouns: Displays pronouns as set in the facesheet.
  6. Status: Shows the current encounter status, such as planned, canceled, or active. Click here to learn more about episode of care statuses. 
  7. Flags: Displays active flags added to the patient’s chart.
  8. Admission Date: The date the patient was admitted. 
    • Note: The anticipated admission date appears here for pre-admission patients in the Planned status.
  9. Anticipated Discharge Date: Expected date of patient discharge.
    • Note: The discharge date appears here for discharged patients in Completed status.
  10. Patient’s DOB: Date of birth with the patient’s age in parentheses. 

Selected Encounter

On the top right of the patient header, you'll find the following information: A screenshot of a computer Description automatically generated

  1. Encounter Status: Shows Planned, In Progress, or Completed to indicate the patient's treatment stage. 
  2. Location assigned: Displays the location of the encounter. 
  3. Level of Care: Shows the assigned clinical level of care
  4. Program: Indicates the program assigned.
    • Note: Programs may be named something different depending on your instance configuration. 
  5. Start Date: Displays the start date of the encounter.
  6. Duration: Shows the duration of the encounter from the start date. 
  7. Click this icon to view previous encounters using the encounter selector. The system allows you to switch between encounters, when you need to create new documentation for a specific encounter. image

Expanded Patient Header

The full patient header displays detailed demographic information from the facesheet. Users can expand or collapse the header at any time without losing their place in the chart. 

Let’s review the full header in Kipu EMR. 

Click the expandable arrow icon to reveal the full patient header.

Each section will be discussed in depth below in numerical order.A screenshot of a computer Description automatically generated

Let’s review the expanded header by sections. Click on the sections to view the contents. 

  • This section contains the patient’s name and date of birth information, as well as their MR number, status, and flags.
    A screenshot of a computer Description automatically generated
    1. Patient Profile Picture: Photo taken at the facility or sent via the patient portal during intake. 
    2. Name Information and Date of Birth
      • Patient Name: First name, last name, with the preferred name in quotation marks. 
      • Date of Birth and Age: Patient’s birthdate with age in parentheses. 
      • Full Name: Patient's first, middle, and last name. 
      • Birth/Maiden Name: Patient’s birth/maiden name (If any) 
    3. Status and Flags 
    4. MR Number: Displays the medical record number, with a drop-down menu to view previous episodes of care. 

    Note: If they are enabled, this section will display patient ID, CID, and state ID information.

  • This section displays information about the patient’s medical team, admission, and stay. 

    • Case Manager: The case manager from the care team form. 
    • Primary Physician: The primary physician from the care team form. 
    • Primary Therapist: The primary therapist from the care team form. 
    • Full Care Team: Click the link to view the Full Care Team assigned to the patient. This screen can be printed.
      A close-up of a computer screen Description automatically generated
    • Admission Date: The date the patient was admitted.
    • Anticipated Admission Date: Expected admission date for the patient. 
    • Building: Building assigned to the patient.
    • Bed: Bed assigned to the patient. 
  • This section contains sobriety and patient demographic information.

    • Sobriety Date: Enable this feature to track the patient’s sobriety
    • SSN: Displays the last four digits of the patient’s Social Security number (required for billing). 
    • Marital Status: Shows the patient’s marital status. This field is customizable in the patient settings
    • Race: Shows the patient’s race. This field is customizable in the patient settings.
    • Ethnicity: Shows the patient’s ethnicity. This field is customizable in the patient settings.
    • Preferred Language: Displays the patient’s preferred language. 
    • Gender: Indicates gender identity, with pronouns in parentheses. 
    • Birth Sex: Indicates birth sex. 
  • This section displays the patient’s discharge information. 

    • Discharge Date: This field remains blank until the discharge workflow is completed. 
    • Anticipated Discharge Date: Expected discharge date for the patient. 
    • Discharge Type: Type of discharge entered during the encounters discharge workflow
    • Discharge To: Facility where the patient has been discharged, if applicable.
  • This section contains the patient’s contact and employment information. The checkmark icon indicates the patient’s preferred contact method. The copy icons allow you to copy the information. 

     

    • Phone Number: Patient’s phone number. Click the icon to copy it. The checkmark indicates the preferred contact method assigned in the facesheet. 
    • Email Address: Patient’s email address. Click the icon to copy it. 
    • Alternative Phone Number: Patient’s alternative phone number. Click the icon to copy it. 
    • Current Address: Patient’s current address. 
    • Alternative Address: Patient’s alternative address. 
    • Occupation: Patient’s occupation.
    • Employer Name: Patient’s employer, if applicable. 
    • Employer Phone: Employer’s phone number, if applicable. 
  • This section displays the patient’s diagnosis, allergies, diet, and eRx pharmacy (if enabled).

    • Diagnoses: Patient’s diagnosis using the correct ICD-10 code(s). Diagnosis codes are required for benefit verification, labs, and billing.
    • Allergies: Patient’s allergies, including drug, food, or environmental. 
    • Diets: Patient’s dietary restrictions. These fields are customizable in the settings.

    Note: This section will display the eRx pharmacy if enabled.

  • This section displays the patient’s contacts. 

    image 

    • Contacts: Patient’s contact name.
    • Phone: Patient’s contact phone number. 
    • Type: Indicates the type of contact. 
    • Relationship: Describes the relationship to the patient. 
  • This section displays the selected payment method (e.g., Insurance, Private Pay) and shows active insurance information. 

    • Company: Insurance company. 
    • Subscriber Name: Insurance subscriber’s name. 
    • Policy Number: Insurance policy number. 
    • Group ID: Insurance group ID. 
    • Insurance Type: Indicate insurance type. 
    • Insurance Card Icon: Click on the icon to view the front and back of the insurance card. This screen can be printed. 
      image
  • This section displays pre-admission information. 

    • Date of First Contact: The date the patient was first contacted. 
    • Rep on Intake Call: Name of the staff representative on the intake call. 
    • First Contact Name: Name of the person who made first contact. 
    • First Contact Phone: Phone number of the first contact. 
    • Relationship to Patient: Describes the relationship to the patient of the person who first contacted the facility. 
    • Pre-Admission Status: Pre-admission status entered during the pre-admission process. 
    • Referrer: Name of the referrer. 
    • Referrer Contact: Indicates whether or not the referrer can be contacted. 
  • This section displays the patient's statuses entered in the facesheet.

    • Status: Patient statuses entered in the facesheet. Use passes or suspended privileges including money, phone, internet access, smoking, etc. 
    • Start: Status start date. 
    • End: Status end date. 
    • Elapsed: Indicates the elapsed days.
  • This section displays client documents. image

    • Client Document Name: Name of the document. 
    • Document Icon: Click the icon to view or review the Patient ID. This screen can be printed. 
  • This section displays assigned tags. 

    • Tag Name: Displays the color-coded tag assigned in the facesheet.
  • This section displays selected encounter details. 

    • Selected Encounter: Shows the status of the encounter, such as In Progress or Completed. 
    • Location: Displays the encounter location. 
    • LOC (Level of Care): Displays the assigned clinical level of care. 
    • Program: Displays the active program assigned to the patient. 
    • Start: Displays the encounter start date. 
    • End: Displays the end date of the encounter. 
    • Duration: Displays the number of days from the start date to the end of the encounter. 

    Encounters Status Drop-Down

    Click on the carrot to show the patient’s encounter history and switch between encounters, if needed.

    The encounters include the following details:

    1. Status: Identifies the patient’s level of care and program and does not impact the documentation process. The encounter status updates automatically based on logged events and depends on the start and end dates assigned when you perform the event.
      • Planned: The start date is in the future.
      • In Progress: The start date is in the past, and there is no end date, or the end date is in the future.
      • Completed: The end date is in the past.
    2. Location: Displays the encounter’s location.
    3. LOC (Level of Care): Assigned clinical Level of Care
    4. Program: Program assigned.
    5. Start Time: Chart creation date and time.
    6. End Time: End date of the encounter. If the patient is discharged, this time will match the discharge date. 
    7. Duration: Show the duration of the encounter from the start day. 

    Click on any completed encounter to add additional items to the encounter, if needed.

 

Was this article helpful?

0 out of 0 found this helpful

Comments

0 comments

Please sign in to leave a comment.