Important Content Update Message
We are currently updating the OP Help Center content for OP 20. We appreciate your patience as we continue to make these updates. To locate the version of your software, navigate to: Help tab > About.

Nurse Only Visits

Version 20.7

Overview

Nurse only visits are documented as Encounters and can include appointment reasons such as Shots, Labs, Weight Checks, Rechecks, etc. Always follow your practice's policy on what information is documented for a Nurse Visit.

Document a Nurse Only Visit

  1. Navigate to Tracking, and click to select the patient you will be working with.
  2. Change the Visit Status by clicking the Visit Status field and selecting the status from the drop-down.
  3. Select a room from the Room field drop-down to display the room where the patient will be seen.
  4. Right-click on the highlighted patient, and select Open encounter.
  5. A confirmation window is displayed asking you to confirm the template for the visit. Click Yes to use the listed template.
  6. Review or change information in sections of the note.
  7. Click the Plan/Orders button.
  8. Follow the steps below for the tabs commonly used for Nurse Visits:
  • Order Immunizations
  1. Click into the Vaccine Name field or click the Add button , and enter the name of the Vaccine.
  2. Select a vaccine from the list.
  3. (Optional) Add Special Instructions.
  4. Click the Department drop-down arrow, and select the Department that will complete the task.
  5. Confirm the Tdy radio button is selected.
  6. Click the Save button  to save.
  7. Repeat the above steps for additional Vaccines.
  8. Once all vaccines have been added, click the Create button.
  • Order Labs
  1. Click into the Diagnostic Test Name field or click the Add button , and enter the name of the Diagnostic Test.
  2. Select a test from the list.
  3. (Optional) Add Special Instructions.
  4. (Optional) Add the Dx code.
  5. Click the Department drop-down arrow, and select the Department that will complete the task.
  6. Click the Save button  to save.
  7. Repeat the above steps for additional Diagnostic Tests.
  8. Once all diagnostic tests have been added, click the Create button.
  1. If the practice will charge for the Nurse Visit, click Coding and select Use Suggested.
  2. Click the X button to close the note.
  3. Click the Save button in the Confirmation window.
  4. Complete the tasks from the Tracking window.
  5. Complete the visit by following the steps below.
  1. Right-click on the nurse visit and select Open encounter.
  2. Click the Summary and review the visit note.
  3. Click the Finalize button.
  4. Click the OK button on the Confirmation window.
  5. From the Tracking window, select Nurse: Finished from the Visit Status drop-down. 
Version 20.6

Note: Nurse only visits can include appointment reasons such as patients coming in for shots, weight checks, rechecks etc. These visits are documented as encounters in the OP software.

Documenting a Nurse Only Visit

  1. Follow the procedure for opening an encounter from the Tracking window.
  2. Click the Yes button in the Confirmation pop-up box  to apply the template associated to the appointment. The Apply Template Dialog is displayed.

  1. Click the OK button.
  2. If a template was not selected when the appointment was scheduled, follow these steps:
  1. Click the All templates field. Begin entering the Name of the Template or click the drop-down menu.
  2. Select the Template to apply. The Apply Template Dialog is displayed.
  3. Click the OK button.


Note: Always follow the practice policy on what information is documented for a nurse visit.

  1. Click the CC/HPI/ROS button. Complete or change information for Chief Complaint and Review of Systems.
  2. Click the Plan/Orders button.
  3. Follow the steps below for the tabs commonly used for nurse visits:
  • Order Immunizations
  1. Click the Imm tab.
  2. In the Vaccine Name field, enter the Name of the Vaccine or click the drop-down menu and select an option from the list.
  3. Click the Checkmark to save.
  4. Repeat the above steps to add additional Vaccines.
  5. Click the Create button.
  6. Click the OK button in the Confirmation pop-up box to create the immunizations task.
  • Order Labs
  1. Click the Lab tab.
  2. In the Diagnostic Test Name field, enter the Name of the diagnostic test or click the drop-down menu and select from the list.
  3. Click the Checkmark button to save.
  4. Repeat the above steps to add additional diagnostic tests.
  5. Click the Create button.
  6. Click the OK button on the Confirmation pop-up box to create the diagnostic test task.
  1. Select Use Suggested from the Coding drop-down menu.
  2. Click the X button to close the note.
  3. Click the Save button in the Confirmation pop-up box. 

Follow the steps below to complete the Task from the Tracking window.

  • Immunizations
  1. Click the Tasks button.
  2. Double-click the Immunization Task. The Enter Vaccine Administration Information window is displayed.
  3. Confirm the Vaccine information, Manufacturer, Expiration date, and Lot number.
  4. Select a Body Site from the drop-down menu.
  5. Select the No counseling provided checkbox.
  6. Click the Save button.The Immunization Order Management window is displayed. If additional Vaccines are required, double-click and follow the above steps.
  7. When all vaccines have been administered, click the Done button.
  • Labs
  1. Click the Tasks button.
  2. Double-click the Diagnostic Test.
  3. Click OK on the Choose Primary Diagnosis, if one is available.
  4. Select a Provider from the Ordered by drop-down menu located on the panel on the right.
  5. Click the Save button. The Diagnostic Tests window is displayed.
  6. Enter the results in the Orders/Results panel.
  7. Click the Save button.
  8. Click the X button to close.
  1. Complete the visit by following the steps below.
  1. Right-click on the Visit
  2. Select Open encounter.
  3. Click the Summary and review the Note.
  4. Click the Finalize button.
  5. Click the OK button on the Confirmation pop-up box.
  6. Select Nurse:Finished from the Visit Status drop-down menu. 

Note - What updates when completing an Immunization

  1. Record information such as lot#, time vaccinated, Vaccinator, Counseling provider into the patient's chart.
  2. Deducts the dose from the vaccine inventory.
  3. Puts a charge onto the Superbill for the vaccine and administration fee ("Add vaccine to superbill" is checked off as the default preference).
  4. Updates the Immunization Registry or creates the file to update the Immunization Registry (available with registries that are capable of interfacing with Office Practicum).