2 Minute Pearls Encounter Templates 1 of 17 2 MINUTE PEARLS AHLTA Encounter Templates Would you like to significantly decrease the amount of buttons you need to select in order to document patient care? Did you know you can customize AHLTA so that the S/O template, diagnoses, orders, procedures and other therapies (pt instructions) you common use are immediately available? Encounter templates are one of the most powerful, yet least utilized, functions of AHLTA. This Pearl will outline how to create and edit your own encounter templates.

2 Minute Pearls Encounter Templates 2 of 17 What can an encounter template do for you? List of Diagnoses List of Common Orders List of Procedures Associated an AIM Form or S/O Template To use a favorite template, select from drop down menu. It allows you to combine your most common list of diagnosis, orders, procedures and other therapies with your favorite AIM Form to (or) template. It loads this data for your ease of use. Other therapies can also be added

2 Minute Pearls Encounter Templates 3 of 17 To access Encounter Template Management: 1) Open TOOLS folder 2) Select TEMPLATE MANAGEMENT

2 Minute Pearls Encounter Templates 4 of 17 To access Encounter Template Management: 1) Open TOOLS folder 2) Select TEMPLATE MANAGEMENT 3) Select SEARCH Button

2 Minute Pearls Encounter Templates 5 of 17 5) Select SEARCH Button 4)Fill out the Encounter Template Search window Search Menu to find the template you wish to view and/or edit. Two common quick search options: a) If you want to edit a template that is listed in your favorites list (i.e. it appears when you access the drop-down list the S/O or A/P module), then you only need to check the box that says “Select from my favorites only” b) If you want to edit a template in one of your clinic folders, search by clinic as owner type

2 Minute Pearls Encounter Templates 6 of 17 7) Select View/Edit button 6) Select the encounter template that you wish to View/Edit

2 Minute Pearls Encounter Templates 7 of 17 From this page, you can customize the following areas of your encounter template: For clinical usefulness, I recommend focusing on the following: Diagnoses, Procedures, Notes Templates (S/O Template), Orders, and Other Therapies (include Active Meds, Problem and Allergies in Autocite area)

2 Minute Pearls Encounter Templates 8 of 17 You can add or remove a Diagnosis, Procedure, S/O template (notes template), or Other Therapies as needed by clicking the desired button associated with the field(s) Order(s) cannot be added, only removed in the View/Edit module. (see previous Pearl #4 -- Order Sets on the Fly -- which describes how to add orders to an encounter template directly from the A/P Module)

2 Minute Pearls Encounter Templates 9 of 17 To Add an item: 1) select ADD button (in this example, we will add a diagnosis. The steps are identical for adding an S/O Template (notes template), Procedures, or Other Therapies)

2 Minute Pearls Encounter Templates 10 of 17 2) The Diagnosis Search window opens.

2 Minute Pearls Encounter Templates 11 of 17 3) Enter desired diagnosis either by name or by ICD-9 code and click Search.

2 Minute Pearls Encounter Templates 12 of 17 4) Select the Diagnosis to be added 5) Click Add Items. If you wish to add more than one diagnosis, simply repeat steps 3, 4 and 5. Once you have added all desired items, move to step 6. 6) Click Done.

2 Minute Pearls Encounter Templates 13 of 17 The edited Diagnoses List now shows the new addition. Repeat the previous steps for adding more diagnoses, procedures, other therapies, and note (S/O) templates. You can reorder the list by highlighting the diagnosis and using the up/down arrows to move it.

2 Minute Pearls Encounter Templates 14 of 17 To remove an item from a list: 1)Highlight the item in the respective list 2)Select Remove.

2 Minute Pearls Encounter Templates 15 of 17 Make sure you select Save or Save As once you have made your changes! You have now successfully created/modified your encounter template!

2 Minute Pearls Encounter Templates 16 of 17 In AHLTA 3.3 the Process is Similar Terms and Sections located from tabs located on the side. Specific items found from taps on the top You can see the encounter template grow here. You can link an AIM form or template to your A/P encounter template section. The linked item and the orders will work as one. This will permit your using a favorite S/O documentation tool at several MTFs. You just create local orders.

2 Minute Pearls Encounter Templates 17 of 17 For More Information… AMEDD AHLTA Homepage – (AKO password required) AHLTA Video Tutorials – nmcp.mar.med.navy.mil/AHLTA/AHLTA%20Training%20Tools/index.htmlhttp://www- nmcp.mar.med.navy.mil/AHLTA/AHLTA%20Training%20Tools/index.html ****(If you would like to receive future versions of the AHLTA 2 Minute Pearls directly, please Lakia Brockenberry at to be added to the distribution