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
|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 occurred.|
|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.|
|Flag as Incomplete checkbox||The Flag as Incomplete checkbox will mark an encounter as unfinished.|
|Set All button||The Set All button toggles the Set Default Note (Set) buttons in the Narrative Exam Notes grid.|
|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.|
|Default (Def)||The Default button applies the default phrase/labels for the selected Narrative Exam note.|
|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|
|Phrase Construction button||The Phrase Construction button opens the Phrase Construction window. Phrase Construction assists with the creation of notes and other text-based descriptions.|