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We are currently updating the OP Help Center content for the release of OP 20. OP 20 (official version 20.0.x) is the certified, 2015 Edition, version of the Office Practicum software. This is displayed in your software (Help tab > About) and in the Help Center tab labeled Version 20.0. We appreciate your patience as we continue to update all of our content.

Patient Encounter: Detail Exam

Version 14.19

About Patient Encounter: Detail Exam

Path: Clinical tab > Patient Chart button > Encounter > New or Open Note button > Detail Exam
Path: Practice Management tab > Patient Chart button > Encounter > New or Open Note button > Detail Exam
Path: Billing tab > Patient Chart button > Encounter > New or Open Note button > Detail Exam

The Patient Encounter helps to code and complete an encounter visit.  The encounter note encompasses both narrative and comprehensive formats. It also allows you to customize the layout of the note.  The note is added to the patient chart.

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
SectionDescription

1

Detail Exam buttonThe Detail Exam button opens the Detail Exam window in the patient's encounter note.
2
Encounter Function buttonsThe Function buttons delete an entire encounter note, edit an encounter note, or save an encounter note.
3
Flag as Incomplete checkboxThe Flag as Incomplete checkbox will mark an encounter as unfinished.
4
All TemplatesThe All Templates field is used to select an encounter template that was created or edited in the Encounter Template Editor.  Predefined information will appear in the encounter when a template is selected.
5
Exam TypeThe Exam Type dropdown is used to select and apply a default Detail Exam template for the Detail Exam patient encounter.
6
Detail Exam gridThe 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 QuestionThe 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. The Templates button lists the templates that are created, edited, and reviewed in the Encounter Templates Editor. Templates are pre-written scenarios you can use in an encounter to document common pediatric diagnoses. Templates include detailed descriptions for the usual pertinent positive and negative findings of a wide variety of illnesses, with a standard assessment, plan and ICD-10 coding. 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.
Version 14.10

About Patient Encounter: Detail Exam Tab

Path: Smart Toolbar > Chart button > Encounters tab > Open Note > Detail Exam tab
Path: Smart Toolbar > Schedule Button > Encounters tab >  Edit button > Detail Exam tab

The Patient Encounter helps to code and complete an encounter visit.  The encounter note encompasses both narrative and comprehensive formats. It also allows you to customize the layout of the note.  The note is added to the patient chart.

The Detail Exam tab documents the findings of the encounter. You can add or modify information in this tab.

Patient Encounter: Detail Exam Tab Map

Number
SectionDescription

1

Encounter Note Editor tabs

The Patient Encounter Note Editor contains the following tabs:

2

Care Plans tabThe Care Plans tab lists, prints, and manages care plans for a patient’s health maintenance schedule.
3
Visit DateThe Visit date field indicates the date that the patient encounter occurred.
4
Prior Notes tabThe Prior Notes tab lists the previous encounter notes and messages.

5

Templates tab

The Templates tab lists the templates that are created, edited, and reviewed in the Encounter Templates Editor. Templates are pre-written scenarios you can use in an encounter to document common pediatric diagnoses. Templates include detailed descriptions for the usual pertinent positive and negative findings of a wide variety of illnesses, with a standard assessment, plan and ICD-10 coding. Included with your installation of Office Practicum are Pediatric specific templates.

6
All TemplatesThe All Templates field is used to select an encounter template that was created or edited in the Encounter Template Editor.  Predefined information will appear in the encounter when a template is selected.
7
Function buttonsThe Function buttons delete an entire encounter note, edit an encounter note, or save an encounter note.
8
Flag as Incomplete checkboxThe Flag as Incomplete checkbox will mark an encounter as unfinished.
9
Exam TypeThe Exam Type dropdown is used to select and apply a default Detail Exam template for the Detail Exam patient encounter.
10
Detail Exam gridThe 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.  
11
Custom QuestionThe Custom Question field adds a custom examination point to a selected group in Detailed Exam grid.