Version 20.10
 This window map article points out some of the important aspects of the window you're working with in OP but is not intended to be instructional. To learn about topics related to using this window, see the Related Articles section at the bottom of this page. |
About Patient Encounter: Detail Exam
Path: Clinical, Practice Management, or Billing tab > Patient Chart button > Encounter > New or Open Note button > Detail Exam
The Detail Exam window documents the findings of the encounter. You can add or modify information in this tab.
Patient Encounter: Detail Exam Map
Number | Section | Description |
1 | Detail Exam button | The Detail Exam button accesses the Detail Exam window in the patient's Encounter Note. |
2 | Encounter Function buttons | The Function buttons delete an entire Encounter Note, edit an Encounter Note, or save an Encounter Note. |
3 | Flag as Incomplete checkbox | The Flag as Incomplete checkbox marks an Encounter as unfinished. |
4 | Visit Status and Room drop-downs | The Visit Status and Room drop-downs allow the user to select the appropriate status and location of the patient. These selections update the Tracking and Calendar Schedule views. |
5 | All Templates | The All Templates field is used to select an Encounter template that was created or edited in the Encounter Template Editor. Predefined information is displayed in the encounter when a template is selected. |
| 6 | Complete List button | The Complete List button provides a complete list of Encounter templates. Included with your installation of Office Practicum are Pediatric-specific templates. |
| 7 | Prior Notes button | The Prior Notes button lists the previous Encounter Notes and messages. |
8 | Exam Type | The Exam Type drop-down menu is used to select a specific exam system. By default, Multi-System is selected. |
9 | Detail Exam grid | The Detail Exam grid documents the findings of the exam. The grid is split into groups (Constitutional, Eyes, Neck, Respiratory, etc). Within each group is a set of examination points to document. You can list examination points as Normal (NL), Abnormal (ABNL), and Skip. The Findings column is a text box where you can input your conclusions. |
10 | Custom Question | The Custom Question field adds a custom examination point to a selected group in the Detailed Exam grid. |
Version 20.8
About Patient Encounter: Detail Exam
Path: Clinical, Practice Management, or Billing tab > Patient Chart button > Encounter > New or Open Note button > Detail Exam
The Detail Exam window documents the findings of the encounter. You can add or modify information in this tab.
Patient Encounter: Detail Exam Map
Number | Section | Description |
1 | Detail Exam button | The Detail Exam button opens the Detail Exam window in the patient's encounter note. |
2 | Encounter Function buttons | The Function buttons delete an entire encounter note, edit an encounter note, or save an encounter note. |
3 | Flag as Incomplete checkbox | The Flag as Incomplete checkbox will mark an encounter as unfinished. |
4 | All Templates | The All Templates field is used to select an encounter template that was created or edited in the Encounter Template Editor. Predefined information is displayed in the encounter when a template is selected. |
5 | Exam Type | The Exam Type drop-down menu is used to select and apply a default Detail Exam template for the Detail Exam patient encounter. |
6 | Detail Exam grid | The Detail Exam grid documents the findings of the exam. The grid is split into groups (Constitutional, Eyes, Neck, Respiratory, etc). Within each group is a set of examination points to document. You can list examination points as Normal (NL), Abnormal (ABNL), and Skip. The Findings column is a text box where you can input your conclusions. |
7 | Custom Question | The Custom Question field adds a custom examination point to a selected group in Detailed Exam grid. |
8 | Complete List button | The Complete List button provides a complete list of encounter templates. Included with your installation of Office Practicum are Pediatric specific templates. |
9 | Prior Notes button | The Prior Notes button lists the previous encounter notes and messages. |
