The previous section detailed steps to opening a note from the Tracking view. This section deals with:
- Message/Prompts when opening a note.
- Parts of an Encounter note.
- The Visit Info section of the note.
- When you first open an encounter note for a patient, Office Practicum may present you with a prompt/message similar to the one below.
|Explanation of prompt/message:|
- Select Yes to apply the template.
The below message prompt shows the sections of the template being applied. You can un-check any section you do not want to apply.
In the below example, the 'Chief Complaint', 'History of Present Illness' and 'Review of Systems' questions will be applied from the template.
- Select OK to apply these sections of the template.
Once you have answered the message prompts, the encounter note will open.
|Note: A note in Office Practicum is divided into sections similar to the SOAP (Subjective, Objective, Assessment, Plan) note. The subjective part of the exam includes sections such as Chief Complaint, History of Present Illness, and Review Of System. Each practice determines how much of the subjective portion of the visit a clinical person (Nurse, MA) finishes. The Objective part of the exam includes sections such as vitals and the exam itself|
See below for an Overview of the Encounter note and the 'visit info' section.
Encounter note: Visit Info Tab