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Provider: Chart a Preventive Exam (Well Visit)

Version 14.19

Overview

You will learn how to complete Well Child visits from this article. You will be guided through the windows of a well visit with steps to easily finish the visit. This section is specific to the provider workflow.

  1. From the Tracking window, highlight the Patient.
  2. Click the Patient Chart button from the Clinical, Practice Management or Billing tab.
  3. If the Disable the Problem List and Allergy pop reminder on Chart is deselected in Global Preferences, a confirmation window is displayed.

  1. Click the OK button or the Cancel button for the confirmation windows. The Patient Chart is displayed.
  2. Click Well Visits in the Clinical section of the Window Navigation Panel. All well visits documented for the patient are displayed , the most recent or current well visit is at the top of the list.

Note: You can decide the number of years to display by selecting the appropriate Dates radio button (Past 5 Years, Past 10 Years or All). The default selection is Past 5 Years.
  1. Click a Note to select it, if a Note is not selected, click the Open Note button.
  2. Click Summary to review the current documentation.

Note: The note summary may display when opening the note if the provider Personalized the Well Visit to always open a Well Visit on the Summary.


  1. Select any or all of the below areas to review, modify, or add information.
  • Interval Hx
  • Vitals/Growth
  • Problem List
  • Medications
  • Allergies
  • History
  • Development
  • Surveys
  • Detail Exam
  • AG/Counseling
  • Plan/Orders
  1. Click Assessment and confirm the correct ICD-10 code(s) is selected.
  2. Click the Coding tab and confirm the correct CPT code. Click the Use Suggested button.
  3. Click Summary and review.
  4. Click the Finalize button. A confirmation window is displayed.
  5. Click the OK button to finalize or Cancel button to return to the Summary window.
  6. Click the X to close the patient chart.
  7. From the Tracking window, select MD: Finished from the Visit Status drop-down menu. 

Note: The Visit Status drop-down menu may be different between practices. Select the appropriate status to indicate that the provider has finished with the patient.
Version 14.10

Overview

You will learn how to to complete Well Child visits from this article. You will be guided through the windows of a well visit with steps to easily finish the visit. This section is specific to the provider workflow.

  1. From the Patient Tracking window, highlight the Patient.
  2. Click the Chart button located on the smart toolbar.
  3. Confirm that the Meaningful Use window displays for the problem list.

  1. Click the OK button or the Cancel button in the Confirmation pop-up box.
  2. Confirm that the Meaningful Use window displays for the patient medication allergies.

  1. Click the OK button or the Cancel button in the Confirmation pop-up box.
  2. Confirm that the Meaningful Use window displays for the patient medication.

  1. Click the OK button or the Cancel button. The Patient Chart window is displayed.
  2. Click the Well Visits tab located from the Main Navigation Panel. All well visits documented for the patient are displayed and the current well visit will be at the top of the list.

  1. Determine how much data to display by selecting the appropriate Dates radio button (Past 5 Years, Past 10 years, or All). The default selection is Past 5 Years.
  2. Click the Open Note button.

  1. Click the Summary button to review the current documentation.

Note: The note summary may display when opening the note if the provider used the Lock feature to always open a Preventive Exam on the Summary.

  1. Select any or all of the below areas to review, modify, or add information.
  1. Click the Detailed Exam tab.
  2. Enter Abnormal Findings and additional Comments.
  3. Click the AG/Counseling button.
  4. Verify and enter additional information.
  5. Click the Assess/Plan tab.
  6. Click the Coding tab.
  7. Verify the correct ICD-10 code(s) is selected.
  8. Click Use Suggested CPT.
  9. Click the Summary tab and review.
  10. Click the Finalize button. A Confirmation pop-up box is displayed. 
  11. Click the OK button to finalize or click the Cancel button to return to the Summary window.
  12. Select MD: Finished from the Visit Status drop-down menu. 

Note: The Visit Status list may be different at each practice. Select the appropriate status to indicate the provider has finished with the patient.