We are currently updating the OP Help Center content for the release of OP 14.19 or "OP 19". OP 19 is a member of the certified OP 14 family of products (official version is 14.19.1), which you may see in your software (such as in Help > About) and in the Help Center tabs labeled 14.19. You may also notice that the version number in content and videos may not match the version of your software, and some procedural content may not match the workflow in your software. We appreciate your patience and understanding as we make these enhancements.

Patient Encounter: Narrative Exam

Version 14.19

About Patient Encounter: Narrative Exam Tab

Path: Clinical tab > Patient Chart button > Encounter > New or Open Note button > Narr Exam
Path: Practice Management tab > Patient Chart button > Encounter > New or Open Note button > Narr Exam
Path: Billing tab > Patient Chart button > Encounter > New or Open Note button > Narr 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 Narrative Exam tab provides a narrative of the exam. Phrase Construction can be used to assist with the creation of the narrative.

Patient Encounter: Narrative Exam Tab Map

Number
SectionDescription

1

Narr Exam buttonThe Narr Exam button opens the Narrative 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
Complete List buttonThe Complete List button provides a complete list of encounter templates.
6
Prior Notes button
The Prior Notes button views prior notes and messages for the selected patient.
7
Set All button
Set All button
8
Set button
The Set button opens the Phrase Construction window.  Within that window, you can change the default phrase/labels for the selected Narrative Exam note.

9

Default (Def)

The Default button applies the default phrase/labels for the selected Narrative Exam note.

8
Set All buttonThe Set All button toggles the Set Default Note (Set) buttons in the Narrative Exam Notes grid.
10
Narrative NoteThe Narrative Note is a text box where you can enter narrative of the exam.  Phrase Construction can be used to assist with the creation of the narrative
11
Phrase Construction buttonThe Phrase Construction button opens the Phrase Construction window.  Phrase Construction assists with the creation of notes and other text-based descriptions.
Version 14.10

About Patient Encounter: Narrative Exam Tab

Path: Smart Toolbar > Chart button > Encounters tab > Open Note > Narrative Exam tab
Path: Smart Toolbar > Schedule Button > Encounters tab >  Edit button > Narrative 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 Narrative Exam tab provides a narrative of the exam. Phrase Construction can be used to assist with the creation of the narrative.

Patient Encounter: Narrative 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
Function buttonsThe Function buttons delete an entire encounter note, edit an encounter note, or save an encounter note.
7
Flag as Incomplete checkboxThe Flag as Incomplete checkbox will mark an encounter as unfinished.
8
Set All buttonThe Set All button toggles the Set Default Note (Set) buttons in the Narrative Exam Notes grid.
9
Set buttonThe Set button opens the Phrase Construction window.  Within that window, you can change the default phrase/labels for the selected Narrative Exam note.
10
Default (Def)The Default button applies the default phrase/labels for the selected Narrative Exam note.
11
Narrative NoteThe Narrative Note is a text box where you can enter narrative of the exam.  Phrase Construction can be used to assist with the creation of the narrative
12
Phrase Construction buttonThe Phrase Construction button opens the Phrase Construction window.  Phrase Construction assists with the creation of notes and other text-based descriptions.