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: Vital Signs and Growth Measurements

Version 14.19

About Patient Encounter: Vital Signs/Growth Measurements

Path: Clinical tab > Patient Chart button > Encounter > New or Open Note button > Vitals/Growth
Path: Practice Management tab > Patient Chart button > Encounter > New or Open Note button > Vitals/Growth
Path: Billing tab > Patient Chart button > Encounter > New or Open Note button > Vitals/Growth

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 Vital Signs window documents the Vital Signs for the patient as well as the Growth Measurements. The Vital Signs and Growth Chart window contains the date/time and result of all vital sign and growth measurements in a patient's chart.

BP Reference = latest NHLBI guidelines, Other Vital Sign Reference = Harriet Lane

Patient Encounter: Vital Signs/Growth Measurements Map

Number
SectionDescription

1

Vitals/GrowthThe Vitals/Growth button opens the Vital Signs and Growth Measurements 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
Vital Signs and Growth Measurement Tabs
  • The Enter Vital Signs tab contains fields for entry of the patient's vitals and growth measurements. 
  • The Growth Charts tab maps the results of the patient’s growth include weight, length, height, head circumference, and the calculated BMI graphs. The curves are based on data from the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion, 2000.
  • The Growth Measurements tab displays the current and previous growth measurements.  These measurements can be excluded from the growth chart by clicking the Exclude checkbox.
  • The Vital Signs Charts tab maps the patients vitals over time including tanner stage, peak flow, pain severity, respiratory rate, temperature, pulse, pulse oximetry,  blood pressure, weight, height, and BMI.
5
Function buttons
The function buttons are used to add a record, edit a record, save a record, cancel a record, and refresh a record.
Version 14.10

About Patient Encounter: Vital Signs Tab

Path: Smart Toolbar > Chart button > Encounters tab > Open Note > Vital Signs tab
Path: Smart Toolbar > Schedule Button > Encounters tab >  Edit button > Vital Signs 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 Vital Signs tab documents the Primary and Secondary Vital Signs for the patient as well as the Growth Measurements. The Vital Signs and Growth Chart tabs contain the date/time and result of all vital sign and growth measurements in a patient's chart.

Patient Encounter: Vital Signs Tab Map

Number
SectionDescription

1

Encounter Note Editor tabs

The Patient Encounter Note Editor contains the following tabs:

2
Vital Signs and Growth Measurement Tabs
  • The Enter Vital Signs tab contains fields for entry of the patient's vitals and growth measurements. 
  • The Growth Charts tab maps the results of the patient’s growth include weight, length, height, head circumference, and the calculated BMI graphs. The curves are based on data from the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion, 2000.
  • The Growth Measurements tab displays the current and previous growth measurements.  These measurements can be excluded from the growth chart by clicking the Exclude checkbox.
  • The Vital Signs Charts tab maps the patients vitals over time including tanner stage, peak flow, pain severity, respiratory rate, temperature, pulse, pulse oximetry,  blood pressure, weight, height, and BMI.

3

Care Plans tabThe Care Plans tab lists, prints, and manages care plans for a patient’s health maintenance schedule.
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
Flag as Incomplete checkboxThe Flag as Incomplete checkbox will mark an encounter as unfinished.
7
Function buttonsThe function buttons are used to add a record, edit a record, save a record, cancel a record, and refresh a record.
8
Primary Vitals tabThe Primary Vitals tab fields include blood pressure, pulse, respiratory rate, temperature. Normative values for blood pressure are calculated according to age, sex, and height using reference data from the National Heart, Lung and Blood Institute.
9
Secondary Vitals tabThe Secondary Vitals tab contains pulse oximetry readings, peak flows, pain severity, and other pulmonary function tests.
10
Growth Measurements tabThe Growth Measurements tab contains the date, patient age, stature, weight, BMI, and Comments on measurements.