Encounter completion — the note & diagnoses

Open the encounter and meet the note writer

Every visit is documented in the note writer — a two-pane workspace. The left pane is the patient’s chart; the right pane is the note. You write the note on the right, and when you save, the left pane turns into a guided Encounter Completion checklist that walks you through diagnoses, orders, charges, follow-up, and medications before you sign.

1. Start the encounter. On the dashboard agenda, hover the patient’s appointment row and click the small ▶ play button that appears on the right (its tooltip reads Begin encounter) — the same button sits on the calendar’s appointment list. Or open the patient’s chart and start a note. The note opens on a tab labelled Note: <patient>.
2. Know the two panes.
   • Left — Chart Review. Tabs for Encounters, Notes, Labs, Imaging, Medications, Immunizations, Prenatal, Brain Health, Procedures, Media, and Letters, plus the patient header strip (vitals, allergies, problems, pharmacies). Immunizations, Prenatal, and Brain Health only appear when the matching organization feature is switched on under Admin → Additional Features — and Prenatal additionally needs an existing pregnancy episode on file for this patient.
   • Right — the note editor. A rich-text editor with bold/italic/underline, a Structured/Flat display toggle, headings, lists, alignment, dictation (microphone), and Save Note.
3. Switch panes whenever you need to. The small ⇆ icon button inside the note’s own tab in the tab strip flips the left pane between chart and completion — hover it and the tooltip reads Switch to Encounter Completion or Switch to Chart Review depending on where you are. It shows only on the active note tab, so you can flip back to the chart mid-visit without losing the completion you’ve started. Staff users don’t get the toggle, because they don’t complete encounters.

Co-edit a note with another clinician

Collaborative editing lets two or more clinicians work on the same saved encounter note and Encounter Completion screen at once, the way several people edit one shared document. Changes merge live over a websocket, so a supervising physician and a resident — or a scribe and a clinician — can build the note together without overwriting each other. It is off by default and is a per-clinician setting (not org-wide): the clinician who owns the encounter must have it enabled for a shared session to be allowed.

1. Turn it on (encounter owner). Open the top-toolbar Settings gear, choose SOAP Notes, then the Settings tab in the Template Manager and check Enable Collaborative Editing. It saves immediately. The same Note Writer Preferences panel also holds Speaker Diarization and your Default Note Display Style.
   • Co-editing only works on a saved encounter. A brand-new, unsaved standalone note can’t be co-edited yet — press Save Note first (see Auto-completion).
2. Edit together. When a second clinician opens the same encounter, they briefly see “Connecting… Waiting for collaboration sync”, then a presence bar appears across the top of the note: a green Connected dot, an “N people editing” count, and a colored avatar with each editor’s initials (hover an avatar for the full name and Active now).
   • Sections that someone is editing highlight with a colored border and lock to whoever is in them, so two people don’t type over the same paragraph. You can unlock a colleague’s section if you need to take it over.
   • Toasts announce when someone joins, leaves, or starts signing.
3. Finalize without collisions. When one clinician begins signing/finalizing the visit, everyone else sees a signing-in-progress lock so two people can’t sign at once. If a signing lock is held too long it can be force-unlocked, then the visit closes through the usual Sign & close step.

With a second clinician in the note the presence bar shows two avatars and any section they’re working in carries their color — their cursor and edits stream in live as the two of you write, and either of you can hand a locked section back and forth.

Write the note, hit Save, and the encounter completes itself

As soon as there is text in the note and you press Save Note, Hero EMR reads what you wrote and automatically switches the left pane into Encounter Completion, pre-filling each section from the note. A plan that says “follow up in three months” sets the follow-up; an assessment of “generalized anxiety disorder” is ready to drop in as a diagnosis. You review and adjust rather than start from a blank form.

1. Type your note and click Save Note. Any free text or dictated/structured content counts. Saving is what triggers completion, and the note needs at least 25 characters of text: an empty or very short note still saves, but produces no diagnoses, orders, charges, follow-up, or instructions.
2. Confirm a re-run if the encounter already has completion data. The first save fills the sections straight away. If you save again on an encounter that already has completion data, a Refresh encounter completion? dialog asks first — Keep existing leaves your reviewed work alone, Run extraction re-reads the note and replaces the existing draft diagnoses, orders, charges, follow-up, and patient instructions. An addendum is analyzed without clearing any of that, so addenda add rather than replace.
3. The completion checklist appears. The left pane now shows collapsible sections: Diagnoses, Orders, Charges, Instructions, Follow-up, and Med Management. Suggested values (for example a 2-week follow-up) are already in place.
4. Work top to bottom, or jump around. Use Expand All / Collapse All at the top to open every section at once. The footer chips — Dx, Orders, E/M, F/U (and Linked once you have both a diagnosis and an order) — are a live progress tracker: each turns green when that part is complete and doubles as a jump link.
5. Finish with Sign & Close Visit. The big button at the bottom finalizes the visit in one step. If something required is still missing, clicking it tells you what to fix instead of signing (see Sign & close the visit).

Add diagnoses (ICD-10)

The Diagnoses section captures the ICD-10 codes for the visit. You can search the full code set, click a frequently-used or favorite code, and reorder the list to set the primary diagnosis.

1. Search by code or description. Type into Search ICD-10 codes… (for example anxiety or F41.1) and press Enter, or click the + button in the box. Either opens the Search ICD-10 Codes window — the inline box itself doesn’t list results. Click a row there to add it to the visit.
   • In that window, Billable codes only hides category headers that a payer would reject, and the specialty filter narrows the list to one specialty’s codes.
   • A green ⓘ next to a description marks an HCC relevant code.
2. Or use the quick lists.
   • Frequently Used Diagnoses — one-click chips for the codes your practice uses most.
   • My Favorite Diagnoses — your personal shortlist. Manage it with the gear or Add favorites (see Favorites).
3. Set the primary and order. Added codes appear under Current Diagnoses. The first one is tagged Primary and every other row carries a Secondary badge — click that badge to promote the row to primary. You can also drag the handle to reorder, star a row to favorite it, or click × to remove it. Adding the first diagnosis turns the Dx tracker chip green.