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Managing PCE

Manual Data Entry

Manual data entry is one way to record patient care encounters. The data entered provides the when, why, what, and who information related to a patient encounter:

Encounter location and date/time

Diagnoses treated

Procedures performed

Practitioner(s)

Historical information about encounters can be entered using the Encounter View action in PCE data entry options to make the patient record more complete. Data capture requirements for historical data are minimal. The historical encounter data is not used for billing and workload. No provider is required and entering only a diagnosis or procedure is okay. Immunizations, pap smears, mammograms, surgeries, etc., done elsewhere may now be recorded and used by the clinical reminders. This includes other VA Medical Centers and non-VA locations (Health Department, private office, etc.).

Automated Data Capture

Scanned encounter forms can be used to capture encounter data relevant to clinical reminders. If the reminders are to be accurate, the forms must capture the data they need.

It is a challenge to keep the forms as simple as possible while still meeting information capture requirements. This may be done by combining information such as immunizations and skin tests with other required preventive procedures and assigning appropriate CPT codes so they will be captured correctly.

There is no perfect encounter form. Everyone who uses these forms will have ideas about how to make them “perfect.” They need to be carefully designed to meet most of the users’ needs, while capturing information for workload and billing purposes. You can’t capture everything for everyone on one form.

August 1996PCE V. 1.0 User Manual87

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