Provider: Chart a Preventive Exam (Well Visit)

Version 14.8

Overview

This section will introduce the users to the steps required to complete Well Child visits. The user 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 icon located on the smart toolbar.
  3. Confirm the Meaningful Use window displays for the problem list.

  1. Click OK or Cancel.
  2. Confirm the Meaningful Use window displays for the patient medication allergies.

  1. Click OK or Cancel.
  2. Confirm the Meaningful Use window displays for the patient medication.

  1. Click OK or Cancel. The Patient Chart window displays.
  2. Click the Well Visits tab located on the left panel of the chart.

  1. All well visits documented for the patient will display and the current well visit will be at the top of the list.
  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.
  11. Confirm the window displays, click the OK button to finalize or Cancel button to return to the Summary window.
  12. Click the dropdown arrow at the Visit Status column and change to MD: Finished.

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