| 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. |
Version 20.3
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.
Note: While these templates provide you with a great starting place, we suggest that each practice review the information included in each template, as well as the orders and workflow, prior to beginning any real patient documentation. |
- Follow the path above to access the Well Visit Template Editor window.
- Select a Template and click the Edit button.
Template Properties
- Review the template properties.
| Property | Description |
|---|---|
| Template | Name given to a template. |
| Appt Type | Selection of a default appointment type when scheduling. Not a requirement to save the template. |
| Min Age (Months) | The minimum age a child must be to receive a prompt for use. This only occurs if the template was not selected at the time of making an appointment. |
| Location | Assignment can be made to view templates by location. |
| Archived | Selection if template is no longer used. |
| Default place of service | A place of service can be selected in this field and will populate the Place of service on the Visit Info window when charting. This is not a required field. |
Well Visit Notes
- Click the Well Visit Notes tab if it is not already selected. Review and edit the fields.
| Field | Description |
|---|---|
| Sex | Gender specific templates can be noted. If a contradiction in patient gender is found, you are prompted to confirm the use of template. |
| Interval History | Information age appropriate for what has happened since last well visit. |
| Developmental Assessment | Developmental Milestones are charted during a visit. Information entered in this field can be used in place or with the milestones charted. |
| Anticipatory Guidance | Age appropriate questions and discussion points. |
| Counseling | Information entered includes counseling that is commonly done during the visit. |
| Assessment/Plan | This describes what will be done to treat the patient – ordering labs, referrals, procedures performed, medications prescribed, etc. This should address what was discussed or advised with the patient as well as timings for further review or follow-up are generally included. |
| Patient Instruct | Instructions entered will be visible on the Patient Portal when the template is selected. Instructions are typically a summary of the visit written for understanding by the reader. |
Add a Diagnosis Code
- Click the Add button.
- Select the Prim? checkbox if the code is the primary diagnosis.
- Click the ICD10 Description field.
- Click the Search button. The ICD10 Search window is displayed.
- Enter a Description or Code in the ICD10 Code/Description field.
- Select the Diagnosis Code.
- Repeat this process for any additional Diagnosis Code to be associated to the well visit (i.e. Counselling for Physical Activity and Nutrition).
Detailed ROS
- Click the Detailed ROS tab. Set the ROS Questions/Symptoms.
| Setting | Description |
|---|---|
| Pert | Relevant symptom/question to display when template is opened. Is not on the finalized note. |
| Confirms | Confirmation of the symptom/question. Is on the finalized note. |
| Denies | Denies the symptom/question. Is on the finalized note. |
| N/A | Not applicable for the template. Removes from the group list. |
Note: To see other Review of Systems groups, select the Show all groups checkbox. |
School Exam
- Click the School Exam tab. Set the School Exam questions. Review or change the default School Exam settings.
- Review or change the default Developmental questions.
Detailed Exam
- Click the Detailed Exam tab. Set the Detailed Exam questions.
| Setting | Description |
|---|---|
| NL | Normal for the the symptom/question. Outputs on the finalized note. |
| ABNL | Abnormal for the symptom/question. Ouputs on the finalized note. |
| Pert | Relevant symptom/question to display when template is opened. Does not output on the finalized note. |
| N/A | Not applicable for the template. Removes from the group list. |
Note: To expand an exam group, click the Heading. To see additional Exam groups, select the Show all groups checkbox. |
- Click to review the Orders/Workflow tab.
- Click to review the Procedures tab.
- Click the Save Changes to template button.
Version 20.2
Path: Clinical tab > Well Visit Templates button
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.
Note: While these templates provide you with a great starting place, we suggest that each practice review the information included in each template, as well as the orders and workflow, prior to beginning any real patient documentation. |
- Follow the path above to access the Well Visit Template Editor window.
- Select a Template and click the Edit button.
- Review the template properties.
| Property | Description |
|---|---|
| Template | Name given to a template. |
| Appt Type | Selection of a default appointment type when scheduling. Not a requirement to save the template. If your practice is recognized as PCMH or working toward recognition for PCMH, be sure to use the Originating and Distant Appointment Types for Telehealth templates so that the visits are accurately calculated for AC06. |
| Min Age (Months) | The minimum age a child must be to receive a prompt for use. This only occurs if the template was not selected at the time of making an appointment. |
| Location | Assignment can be made to view templates by location. |
| Archived | Selection if template is no longer used. |
- Click the Well Visit Notes tab if it is not already selected. Review and edit the fields.
| Field | Description |
|---|---|
| Sex | Gender specific templates can be noted. If a contradiction in patient gender is found, you are prompted to confirm the use of template. |
| Interval History | Information age appropriate for what has happened since last well visit. |
| Developmental Assessment | Developmental Milestones are charted during a visit. Information entered in this field can be used in place or with the milestones charted. |
| Anticipatory Guidance | Age appropriate questions and discussion points. |
| Counseling | Information entered includes counseling that is commonly done during the visit. |
| Assessment/Plan | This describes what will be done to treat the patient – ordering labs, referrals, procedures performed, medications prescribed, etc. This should address what was discussed or advised with the patient as well as timings for further review or follow-up are generally included. |
| Patient Instruct | Instructions entered will be visible on the Patient Portal when the template is selected. Instructions are typically a summary of the visit written for understanding by the reader. |
- Add a Diagnosis Code.
- Click the Add button.
- Select the Prim? checkbox if the code is the primary diagnosis.
- Click the ICD10 Description field.
- Click the Search button. The ICD10 Search window is displayed.
- Enter a Description or Code in the ICD10 Code/Description field.
- Select the Diagnosis Code.
- Repeat this process for any additional Diagnosis Code to be associated to the well visit (i.e. Counselling for Physical Activity and Nutrition).
- Click the Detailed ROS tab. Set the ROS Questions/Symptoms.
| Setting | Description |
|---|---|
| Pert | Relevant symptom/question to display when template is opened. Is not on the finalized note. |
| Confirms | Confirmation of the symptom/question. Is on the finalized note. |
| Denies | Denies the symptom/question. Is on the finalized note. |
| N/A | Not applicable for the template. Removes from the group list. |
Note: To see other Review of Systems groups, select the Show all groups checkbox. |
- Click the School Exam tab. Set the School Exam questions.
- Review or change the default exam settings.
- Review or change the default Developmental questions.
- Click the Detailed Exam tab. Set the Detailed Exam questions.
| Setting | Description |
|---|---|
| NL | Normal for the the symptom/question. Outputs on the finalized note. |
| ABNL | Abnormal for the symptom/question. Ouputs on the finalized note. |
| Pert | Relevant symptom/question to display when template is opened. Does not output on the finalized note. |
| N/A | Not applicable for the template. Removes from the group list. |
Note: To expand an exam group, click the Heading. To see additional Exam groups, select the Show all groups checkbox. |
- Click to review the Orders/Workflow tab.
- Click to review the Procedures tab.
- Click the Save Changes to template button
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