| OP sets all defaults to share all information. Any individual decisions by Practice-users to restrict information sharing (access, use, or exchange) are the responsibility of the Practice in the implementation of its 21st Century Cures Act Information Blocking policies and procedures for its Practice and patients. |
Version 14.19
 This window map article points out some of the important aspects of the window you're working with in OP but is not intended to be instructional. To learn about topics related to using this window, see the Related Articles section at the bottom of this page. |
About Patient Chart: Miscellaneous Notes
Path: Clinical, Practice Management, or Billing tab > Patient Chart button > Notes/Addl Info
The Miscellaneous Notes window allows you to add or edit visit notes to the Patient Chart. In the Miscellaneous Notes tab, input the necessary fields as required by the office staff for the patient(s).
Note: Just like a paper chart, the electronic chart in OP contains personal health information and should be kept protected and confidential. Always close all windows on your screen and log out of OP when you are not at your workstation. |
Patient Chart: Miscellaneous Notes Map
Number | Section | Description |
1 | Notes/Addl Info button | The Notes/Addl Info button accesses the Miscellaneous Notes window in the Patient Chart. |
2 | Default Well Visit Type | This field is used to set the default Well Visit Type for the patient, such as an Extended Appointment Type. If an appointment type is associated with a visit template selected for the appointment reason, OP prompts the user to pick the patient's default or to use what is associated with the appointment reason populated. |
3 | Default Sick Visit Type | This field is used to set the default Sick Visit Type for the patient, such as an Extended Appointment Type. If an appointment type is associated with a visit template selected for the appointment reason, OP prompts the user to pick the patient's default or to use what is associated with the appointment reason populated. |
4 | Employed/Student | Defaults to Part-time student/not employed, but should be edited as necessary for the specific patient. |
5 | Marital Status | Defaults to Single, but should be edited as necessary for the specific patient. |
6 | Miscellaneous Notes | The Miscellaneous Notes field is used to document a note in the patient's chart, such as if the patient is chronically late to or misses scheduled appointments. Be mindful of the language used in notes for patients. The system has an extensive audit trail to notes, even after they are deleted out of a chart. |
7 | Billing Notes | The Billing Notes field is used to document a billing-specific note in the patient's chart, such as if they need to contact their insurance for billing purposes, like Coordination of Benefits (COB). Be mindful of the language used in notes for patients. The system has an extensive audit trail to notes, even after they are deleted out of a chart. |
8 | Referred to the practice by | This field can be used to document who referred the patient to the Practice if the office keeps track of that information. Clicking the Add button opens the Address Book window. |
Version 14.10
About the Patient Register: Misc/Notes Tab
Path: Smart Toolbar > Register button > Misc/Notes tab
Whether a new patient is entering your practice or your practice is transitioning from paper to electronic records, creating a Patient Register record is the first step in registering a patient in your database. The Patient Register assigns each patient a unique patient ID number, and automatically creates a Patient Chart for the patient.
Using the patient register you can:
- Link Families
- Confirm a new patient needs to be registered
- Register a new patient
- Print a patient’s demographics
- Copy a sibling’s register record
- Add relatives or contacts to a patient’s register record
- Add, edit, copy or validate insurance
- Add miscellaneous notes
- Add privacy restrictions
- View and add consent forms
- View and add to the patient’s coordination of care
- Change the family address.
The Patient Misc/Notes tab allows you to add or edit visit notes to the patient register. In the Misc/Notes tab, input the necessary fields as required by the office staff for the patient(s).
 | Note: You can create a popup in the Misc and Billing notes by entering two @@ signs in front of the text typed. |
Patient Register: Misc/Notes Tab Map
Number | Section | Description |
1 | Patient Registration Category Tabs | The Patient Register contains the following tabs: |
2 | Function buttons | The function buttons allow the user to print, create, delete, edit, save, and cancel the insurance information displayed or entered in the patient register. Not all tabs in the patient register will be available for printing (i.e the Misc/Notes tab). |
3 | Default Well Visit Type | If there is a patient that always needs a specific type of Well Visit, like an extended Well Visit, due to medical issues, an office may select from the dropdown Default well visit type, as long as there is an option that is entered into the set up of appointment types. If an appointment type is associated with a visit template selected for the appointment reason, OP will prompt the user to pick the patient's default or to use what is associated with the appointment reason populated. If the appointment type is blank with a visit template selected for the appointment reason, OP will automatically pick the patient's documented default appointment reason from this screen. If the appointment reason selected is not associated with a template, the appointment types that are default for the patient will be highlighted for a user to easily select. |
4 | Default Sick Visit Type | If there is a patient that always needs a specific type of Encounter Visit, like an extended Sick Visit, due to medical issues, an office may select from the drop-down Default sick visit type, as long as that is an option that is entered into the set up of appointment types. If an appointment type is associated with a visit template selected for the appointment reason, OP will prompt the user to pick the patient's default or to use what is associated with the appointment reason populated. If the appointment type is blank with a visit template selected for the appointment reason, OP will automatically pick the patient's documented default appointment reason from this screen If the appointment reason selected is not associated with a template, the appointment types that are default for the patient will be highlighted for a user to easily select. |
5 | Miscellaneous Notes | If there is a patient that needs a specific type of note on their account, because that patient is chronically late or missing scheduled appointments, the Miscellaneous Notes field may be used for this field. Be mindful of the language used in notes for patients. The system has an extensive audit trail to notes, even after they are deleted out of an account. |
6 | Billing Notes | If there is a patient that needs a specific type of note on their account, because that patient needs to contact their insurance for billing purposes, like Coordination of Benefits (COB) , the Billing Notes field may be used for this field. Be mindful of the language used in notes for patients. The system has an extensive audit trail to notes, even after they are deleted out of an account. |
7 | HFCA Line 8 | Since Office Practicum is a pediatric based software, the defaults set for information on a claim for Employment and Marital Status are done for you. Please edit as necessary for specific patients. |
8 | Referred to the practice by | If the office keeps track of who refers a patient to their practice, manually input that reference, or select the Add button, which will open the Address Book. A user may select the reference from the address book if that reference is already added in the address book. If the incorrect reference was added, click on to Reset button to clear the selection. |
