About Patient Encounter: History Tab
Path: Smart Toolbar > Chart button > Encounters tab > Open Note > History tab
Path: Smart Toolbar > Schedule Button > Encounters tab > Edit button > History 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 History tab documents a patient’s history. The Patient History captures and displays multiple sections of the patient's history (Past Medical, Family History, Social History, and Perinatal History) in a simple-to-use and easy-to-read format.
Patient Encounter: History Tab Map
|Encounter Note Editor tabs|
The Patient Encounter Note Editor contains the following tabs:
|Care Plans tab||The Care Plans tab lists, prints, and manages care plans for a patient’s health maintenance schedule.|
|Visit Date||The Visit date field indicates the date that the patient encounter occured.|
|Prior Notes tab||The Prior Notes tab lists the previous encounter notes and messages.|
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.
|Function buttons||The Function buttons delete an entire encounter note, edit an encounter note, or save an encounter note.|
|Pertinent History Reviewed checkboxes||The Pertinent History Reviewed check boxes indicate that pertinent history notes have been reviewed.|
|History tabs||The history tabs documents or reviews based on the historical note categories:|