Comprehensive encounters

Intellia EHR provides a comprehensive electronic encounter module that allows healthcare providers to document all aspects of a patient visit clearly and efficiently. The encounter captures the following sets of data:

• General information – Includes visit type and reason, branch, department, physician, and room number.
• Vital signs – Records pulse, blood pressure, oxygen saturation, body temperature, height, weight and BMI.
• Clinical notes – Physicians can enter free-text notes (e.g., using the SOAP method) or select from predefined templates suited for specific specialties.
• Diagnoses – Supports coding with ICD-10 or ICD-11, along with optional free-text clinical diagnoses to describe the context of the condition.
• Medication prescriptions – Allows prescribing medications directly during the encounter.
• Referrals – Issues referrals for diagnostic procedures, specialist consultations, lab analyses, immunizations, and other medical services.
• Health monitoring and chronic disease screening – Enables identification of at-risk patients, tracking of health trends, and supports preventive care and chronic disease management during visits.
• Service management – Tracks and manages services provided during the visit, such as follow-up consultations with the family doctor.

This structured yet flexible approach ensures accurate documentation, improves continuity of care, and streamlines clinical workflows.