Once a survey has been completed for a patient, the best way to print it is from the Event Chronology.

If you routinely do an Asthma Action Alan at your asthma maintenance visits, you can add it as a standing order to your template for the doctor to complete. To add a standing order to your templates, navigate to Clinical tab > Encounter Templates.

1. Select the template you would like to add the task for the asthma action plan.
2. Double click on the template or highlight and select Edit.
3. Click on the Orders/Workflow Tab.
4. Select the Other Tasks tab, and click "+" to create new Task.
5. In the Task Description field, enter a description. Example: Update Asthma Action Plan.
6. In Task Type field, select Asthma Plan from the drop-down.
7. Click the drop-down in the Department field, and select the department responsible for completing the Asthma Action Plan.
8. In the Usage field, click the drop-down and select Standing.

When the template is applied to the visit, the task for the Asthma Action Plan will be automatically created. Clicking on the task will open the Asthma Action Plan. This order will show in the Summary of your note, so it will be clear that it was completed during the visit.

Nurses/MA's do not need to choose a rendering provider for each visit. When the provider logs into the note that was started by the nurse for the first time, OP will automatically enter them as the rendering provider.  If the provider who logs in is not the provider whose schedule the appointment has been made, they will get the pop up asking them to claim the appointment.

There could be two reasons as to why there are two notes opened.

Reason 1:

• A staff member already right clicked to open an encounter, and another staff member right clicked to open a well visit. The incorrect note will need to be deleted.

Reason 2:

• If a staff member was trying to add a sick encounter onto a well visit there are actually two notes that exist: one that is in relation to the well visit, and one that is in relation to the sick encounter.

To delete a well visit note, follow the steps below:

1. Go to the patient chart and open the existing well visit note.
2. Click on the red minus sign at the top of the screen to delete the note.
3. Click Ok in the popup.
4. Type the reason you are deleting the note and click Ok.

You can utilize Medical Record to view a prior note while documenting a well visit. You can open Medical Records in the background, or select the Personalize tab and select Use tabbed interface to navigate between the windows. 

You can enter notes to appear on the school form in 2 places:

• Patient Chart > Overview Tab > Health Summary Recommendations field (lower right hand corner)
• Well Visit > School Exam > Exam Note Field

This is up to the practice. If you use a note it will not appear in the survey section. You can also indicate this using the Risk Assessment.

When you add diagnoses to a template you have a checkbox to indicate if it is primary diagnosis.If there is more than one diagnosis marked as primary, you will get a popup box when the template is applied asking you to choose the primary diagnosis for this visit. For example, if you chose to include left otitis media, right otitis media, and bilateral otitis media as primary, when you apply the template those 3 diagnoses will appear and you will select one. Any additional diagnoses such as URI that you added to the template, but did not mark as primary will be added to your note automatically.

You are able to have the Search Appt window open independently of the Calendar, so you can keep that open behind your windows if you like and then bring it up when you are trying to see future appointments for a patient. 

No, OP does not change the code based on the appointment type.  

It is the responsibility of the provider to confirm that a patient really is a new patient based on CPT rules, which are not necessarily the same rules your practice might use to classify a patient as new vs. established.  For example:  

The school exam of the well visit is used to populate school forms that are printed out of OP. This gives you the control over what is included in the school form, which may not include all of what you documented in your exam. You do not need to have this show up in the summary of your note, as it will still generate the school forms. Just remember to complete the school exam tab so that your forms are accurate.

To change this, go to the summary tab of a well visit (you can also do this under Utilities).

1. Click on Edit Criteria.
2. Select Encounter Sections tab.
3. Uncheck include School Exam findings (well visits).

If you have already finalized the note for a visit and would like to add more information, you can create an addendum. Click here to see the instructions for how to do this. 

While creating either a Well or Encounter Visit, there is a field on the Visit Info tab for Staff Chaperone. If a chaperone is selected from the drop down, it will appear in the Summary of both types of notes, provided that the Providers checkbox is checked in Report Criteria/Encounter Sections.

The primary and secondary insurance can be seen at the top of the Overview tab within the patient's chart.

Path: Clinical tab > Well Visit Templates

Overview

All of the Office Practicum Well Visit Templates were created by our Medical Director, Susan Kressly, M.D., F.A.A.P.  These templates are based off of the Bright Futures Guidelines and contain Bright Futures Anticipatory Guidance, Developmental Milestones, Pre-Visit Surveys, Developmental Surveys, Patient/Parent Educational Handouts, and other items following Bright Futures recommendations.

1. Navigate to the Well Visit Template Editor window using the path above.
2. Click the Add button.

Complete the Well Visit Template Properties

1. Add the template properties using the table definitions below. 

Complete the Well Visit Notes Tab

1. Click the Well Visit Notes tab if not already selected. Add information using the table definitions below. 

1. Add a diagnosis code:

1. Click the Add button.
2. Click the Prim? checkbox if the code is the primary diagnosis.
3. Click into the ICD10 Description field.
4. Click the Search button. The ICD10 Search window displays.
5. Enter a description or code in the ICD10 Code/Description field.
6. Select the diagnosis code.
7. Click the SNOMED link button.
8. Select the SNOMED code.
9. Click the Save Entry button.

Complete the Detailed ROS Tab

1. Click the Detailed ROS tab.
2. Click the Expand button to expand an ROS group.
3. Set the ROS Questions/Symptoms using the following:

• First click indicates NL (normal).
• Second click indicates ABNL (abnormal).
• Third click indicates Pert (pertinent)
• Fourth click indicates N/A

Complete the School Exam Tab

1. Click the School Exam tab. 
2. Set the School Exam answers. 
3. Enter the Developmental answers.

Complete the Detailed Exam Tab

1. Click the Detailed Exam tab.
2. Click the Expand button.
3. Set the Detailed Exam questions using the following: 

• First click indicates NL (normal).
• Second click indicates ABNL (abnormal).
• Third click indicates Pert (pertinent)
• Fourth click indicates N/A

Complete the Orders/Workflow Tab

1. Click the Orders/Workflow tab.
2. Complete the Medications, Diag Tests, Immunizations, Resources, Surveys, Followup, and Other Tasks tabs using the controls at the bottom of the window.

Complete the Procedures Tab

1. Click the Procedures tab.
2. Select the CPT Codes that apply to the template.
3. Click the Save button  to save your template changes.

Version 14.10

Utilities > Manage Clinical Features > Well Visit Template Editor

Overview

All of the Office Practicum Well Visit Templates were created by our Medical Director, Susan Kressly, M.D., F.A.A.P.  These templates are based off of the Bright Futures Guidelines and contain Bright Futures Anticipatory Guidance, Developmental Milestones, Pre-Visit Surveys, Developmental Surveys, Patient/Parent Educational Handouts, and other items following Bright Futures recommendations.

It is not our best practice for an office to create more than one template for each age group. This can make it difficult for your staff to choose the appropriate template for a patient.

1. Click the Utilities button on the menu toolbar .

Menu Toolbar: Utilities

1. Select Manage Clinical Features.
2. Select Well Visit Template Editor. The template list will display.
3. Click the Create a new template button .
4. Add the template properties using the table definitions below. 

Well Visit Template Editor: Template Properties

1. Click the Well Visit Notes tab if not already selected. Add information using the table definitions below. 

Well Visit Template Editor: Well Visit Notes Tab

1. Add a diagnosis code:

1. Click the Add button.
2. Click the Prim? checkbox if the code is the primary diagnosis.
3. Click into the ICD10 Description field.
4. Click the Search button. The ICD10 Search window displays.
5. Enter a description or code in the ICD10 Code/Description field.
6. Select the diagnosis code.
7. Click the SNOMED link button.
8. Select the SNOMED code.
9. Click the Save Entry button.

1. Click the Detailed ROS tab.
2. Click the Expand button .
3. Set the ROS Questions/Symptoms using the table descriptions below. 

Well Visit Template Editor: Detailed ROS Tab

1. Click the School Exam tab. Set the School Exam answers. Here is a list of what is defaulted in the pre existing Well templates.

Well Visit Template Editor: School Exam

1. Enter the Developmental answers.

Well Visit Template Editor: Developmental

1. Click the Detailed Exam tab.
2. Click the Expand button .
3. Set the Detailed Exam questions using the table definitions below. 

Well Visit Template Editor: Detailed Exam Tab

1. Click the Orders/Workflow tab .
2. Click the Procedures tab .
3. Click Save Changes to template button .

OP's best practice is to create Procedure Templates for all procedures that are performed in office. Some examples are: Nebulizer Treatment, Circumcision, Ear Lavage, Rocephin Injection, etc. If one of the procedure templates is needed during a visit, then the Nurse/MA or Provider would layer the template into the Encounter. The template would already have the specifics related to the procedure, such as tasks, medications, follow-up protocols, etc.

Click here to learn how to create procedure templates.

There are several triggers that generate charges for a patient when documenting a visit:

• A provider adds the CPT code(s) in the Coding tab of the visit.

• A vaccine is documented.  It is not necessary for the provider to code the vaccine administration CPT code in the visit.  OP automatically applies the admin code based on the charting of the vaccine itself.  For example, if a vaccine is given and noted that counseling was performed, OP will automatically add 90460 and 90461 (if appropriate).  If no counseling occurred, OP will add the 90471 and 90472 (if appropriate).

• An in-house test or procedure is coded with a corresponding check in the $ box.

• A Survey is carried out and marked Informed or Completed.

• A template is applied to a visit that contains Standing Orders with CPT codes attached.

If the note is unfinalized or in Edit mode:

1. Go to the patient's chart and open the note.
2. Search all sections where free text was entered (including ROS and Exam comments) for an open '{'.
3. Edit the text, so the beginning and ending brackets are the same.  By using '[' brackets, the text within the brackets will appear bold on the summary sheet.
4. Rebuild the summary.

If the note has been finalized, contact OP Support at 800-218-9916, option 2.

To change the visibility of a finalized note, follow the steps below:

1. Open the Patient's Chart.
2. Select Encounters or Well Visits.
3. Select the note to change the visibility level and click Open Note.
4. Select the appropriate visibility from the Visibility drop-down located at the bottom of the note.
5. Click the Save button.

To view a finalized note:

1. Click the Chart button on the main menu.
2. Click the Encounters tab.
3. Select the encounter note and click the Open Note button.
4. Click the Summary tab.
5. Select the checkbox for Include Records/sections with limited visibility (EFR) in the Summary Report Criteria field group.
6. Click the Alternate Notes tab.
7. Click the Rebuild Summary button.
8. The section that was set for higher visibility will populate under the Alternate Notes tab.

OP sets all defaults to share all information. Any individual decisions by Practice-users to restrict information sharing (access, use, or exchange) are the responsibility of the Practice in the implementation of its 21st Century Cures Act Information Blocking policies and procedures for its Practice and patients.

Versions previous to OP 14.8.30 defaulted to Rectal as the temperature-measurement method for patients younger than 180 days. Providers had to change the measurement method manually for each patient. OP 14.8.30 allows you to set a default method of measuring temperature for patients younger than 180 days old (in addition to patients older than 180 days old).

To set a default method of taking the temperature of patients less than 180 days old:

1. Log on to OP 14 with a logon account that has Administrator permissions.
2. Click Utilities / System Admin / System Preferences.
3. Click on the Special tab.
4. Click on the Medical tab. The Default Method Used for Measuring Temperature now has two rows of default settings. The top set of radio buttons is for patients less than 180 days old (Rectal is still the default setting). The bottom set of radio buttons is for patients older than 180 days old.
5. In the top row of radio buttons, select the method for measuring temperature that you want to set as the default for all patients less than 180 days old.

1. Click the Exit button to save your changes and exit the System Preferences window.

When patients are due or overdue for their well visit, their Last well visit field will be indicated in red in the Overview tab of their Chart. Additionally, the date of the last well visit will appear.

Patients who have not had a well visit will also have a Last well visit field red indicator in the Overview tab of their Chart. However, the Last well visit field will not contain a date.

While searching for a diagnosis code, you have the option of searching by 'Patient recent'. This option will display diagnosis codes that have been saved in an encounter or well visit note or are listed in an active problem in the patient's problem list.

Yes, the ICD-10 code set is maintained by Office Practicum via Health Language (HL) updates. 

• HL content is updated on a monthly basis, and content is released on an intermittent basis (determined by the vendor). 
  • HL only returns codes that are appropriate for billing purposes.
  • Any codes that have been retired from HL will no longer be available in OP for selection.
• Once it is determined that an ICD-10 code has been excluded from Health Language content, users should review their templates to update codes as necessary. 
• Client Server and Cloud clients both use the same endpoint for communication, so there is no difference in updating one versus the other.

In the Schedule tab within the System Preference window there is a preference to "Automatically reset visit stage when encounter notes are opened." This setting only applies to the lowest sort number for the following OP stages:  

• Nurse/triage
• Doctor

Once a staff member with a Clinical level of the "Clinical Staff" or higher (which is set in the Staff Directory) opens the Encounter note, the Visit Stage in Tracking will automatically change to the lowest sort number for that stage (see example below). 

• Once the Clinical staff member opens the encounter, the Visit Stage in Tracking will automatically change to the lowest sorted stage for Nurse/triage (we suggest Nurse: In Progress). 
• Once the Provider opens the encounter, the Visit Stage in Tracking will automatically change to the lowest sorted stage for Doctor (we suggest  MD: In Progress).

Review the image below. In order for the Nurse: In Progress and MD: In Progress to be the automated stages, the Patient Tracking Stages setup should appear as follows. 

It is the recommendation of the CDC that the CDC growth reference charts should be used  when a child reaches 24 months. This requires a switch from the WHO growth standards charts.

In OP, the switch to the proper growth chart can be accomplished by a setting in System Preferences. Verify your practice's growth chart setting:

1. Select Admin > Global Preferences
2. Click the Special tab
3. Confirm the Default growth chart for new patients is set to WHO/CDC.
4. If the WHO/CDC chart is not selected, click the drop-down and select WHO/CDC.
5. Click Exit to save.

All patients that were not using the WHO/CDC growth chart selection will need to be changed manually. Once changed the new growth chart selection is remembered. To manually change the growth chart settings for a patient:

1. Select Patient Chart and search for and select a patient.
2. Change the default growth chart using one of the below methods.

• Click the Vitals/Growth tab.
• Charting an Encounter or Well Visit note:

1.  Click the Encounter or Well Visit tab.
2. Open a previous note or start a new note.
3. Click Vitals/Growth.

1. Click the drop-down arrow on the Growth Measurement section and select WHO/CDC.

From the Schedule and Practice Workflow window, if a user selects the All radio button for the Date Range field, the Include Finalized button will not render finalized notes for the Encounter and Well Visit tabs. This is intended functionality due to the amount of notes that would display on each of these tabs.

The references OP use for vital signs are:

• BP: NHLBI guidelines
• All Other Vitals = Harriet Lane

To use the premie growth curve, for growth measurements and growth charts, the following information must be entered.

1. Navigate to the patient chart from Clinical, Practice Management or Billing tab.
2. Click the Patient Chart button and search for the patient.
3. Click History.
4. Select the Birth Info tab.
5. Click the drop-down arrow for Gestational Age and select from the list.

1. Enter measurements in Birth Measurements section.
2. Click Vitals/Growth and select the Use premie growth curves checkbox.

To save a PDF of an Encounter or Well Visit Note:

1. Change the output selection located in the upper right-hand corner of OP to Preview.

1. Navigate to and open the note that will be saved as a PDF.
2. Click the Print Note button. The Print Preview window is displayed.

1. Click the Printer icon in the Print Preview window.
2. Select the Print to File checkbox and complete the Print to File fields:

• Type: PDF File
• Where: Use the browse button  to select where you want to save the PDF.

1. Click OK. The note is saved as a PDF in the specified location.
2. Complete the Medical Record Disclosure window.

To change the default phrase used in a Narrative exam when the Def button is selected:

1. From the Narrative Exam, click the Set All button.
2. Click the Set button for an exam group. The current default phrase is displayed in red.

1. Click to select the phrase that is the new default, right-click and select Set label as Default.

1. Click the Done button.
2. Repeat the above steps to change additional defaults.

Handouts will display when you highlight a diagnosis code and right-click. Handouts will only be available if the diagnosis code has been associated in the AAP Local Content Library. For additional information on adding diagnosis codes to handouts, click here.

The load speed of phrase construction directly correlates to the number of pages and labels (phrases). Please discard any phrases that aren't used frequently in order to optimize speed. See this article for more information.

Use the Dates radio buttons located at the top of the Encounters and Well Visits sections of the Patient Chart to display:

• Past 5 years
• Past 10 years
• All

The radio buttons apply only to the section from which they are being accessed. For example, to show the past 10 years of a patient's Well Visits, go to the Well Visits section of the chart and select the Past 10 Years radio button. To see the past 10 years of a patient's Encounters, go to the Encounters section of the chart and select the Past 10 Years radio button.

A Well Visit note in Office Practicum is divided into sections which include conducting an interval history, a developmental screening, an exam, anticipatory guidance/counseling, screening tests, etc. Each practice determine how much of the note is completed by the Clinical Staff.

An Encounter 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 is entered by the Clinical Staff. The Objective part of the exam includes sections such as vitals and the exam itself.

Questions in the Well Visit templates vary depending on the age of the patient. Additionally, starting at age 9, templates are also differentiated by gender (Male or Female). When the Front Desk staff schedules the appointment, they will select the reason for the visit based on the age of the patient. For patients 9 years old and above, they will also distinguish between Male or Female.

When applying the template to a Well Visit note, if the appointment reason does not match the Office Practicum will alert the user if the appointment reason (template) does not match the patient, a Warning message is displayed.