Patient Encounter: Detail Exam

Version 20.10

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
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
Visit Status and Room drop-downs
The Visit Status and Room drop-down menus allow the user to select the appropriate status and location of the patient. These selections update the Tracking and Appointment windows.
5
All TemplatesThe 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.
6Complete List button
The Complete List button provides a complete list of encounter templates. Included with your installation of Office Practicum are Pediatric specific templates.
7Prior Notes button
The Prior Notes button lists the previous encounter notes and messages.
8
Exam TypeThe Exam Type drop-down menu is used to select a specific exam system. By default Multi-System will be selected.
9
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.  
10
Custom QuestionThe 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
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 is displayed in the encounter when a template is selected.
5
Exam TypeThe 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 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 buttonThe Complete List button provides a complete list of encounter templates. Included with your installation of Office Practicum are Pediatric specific templates.
9
Prior Notes buttonThe Prior Notes button lists the previous encounter notes and messages.