Patient Encounter: Narrative Exam

Version 14.8

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
Section
Description

1

Encounter Note Editor tabs

The Patient Encounter Note Editor contains the following tabs:


2

Care Plans tab
The Care Plans tab lists, prints, and manages care plans for a patient’s health maintenance schedule.
3
Visit Date
The Visit date field indicates the date that the patient encounter occurred.
4
Prior Notes tab
The 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 buttons
The Function buttons delete an entire encounter note, edit an encounter note, or save an encounter note.
7
Flag as Incomplete checkbox
The Flag as Incomplete checkbox will mark an encounter as unfinished.
8
Set All button
The Set All button toggles the Set Default Note (Set) buttons in the Narrative Exam Notes grid.
9
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.
10
Default (Def)
The Default button applies the default phrase/labels for the selected Narrative Exam note.
11
Narrative Note
The 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.