Preventive Exam

Version 14.8

About Preventive Exam

Path: Smart Toolbar > Chart button > Well Visits tab > + Start New Note (or Open Note button)

The Preventive Exam window charts a patient well-visit exam. The Preventive Exam window helps to code and complete a preventive encounter visit.  The preventive exam 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.

Preventive Exam Map

Number
SectionDescription

1

Well Visit Note EditorThe Well Visit Note Editor documents the patient encounter.  The Well Visit Note Editor contains the following tabs:
  • Visit Info: Displays the details of the visit such as time, date, place, type, nurse, provider, supervised, and staff chaperone.
  • Interval Hx: The Interval Hx tab documents the patient’s interval history and review of systems.  You can use the Phrase Construction map if needed.
  • Problem List: The Problem list sets the PMFS History/Meds reviewed within the assessment on the exit note.  It creates a problem list, shows scanned items, and adds/edits chart note worksheets.
  • Allergy/Rxn: The Allergy/Rxn displays and documents allergy and vaccine reactions.
  • Med Review: The Med Review tab displays and documents patient medications. 
  • Immunizations: The immunizations tab accesses the patient’s immunization chart.
  • History: The history tab documents a patient’s past medical history, family medical history, social history, and perinatal history.
  • Risk Assesses: The Risk Assessment tab displays the risk assessment list.  Using the Risk Assessment list, you can choose the current risk factors and use them in the care plans for your patients. This helps with using OP for Meaningful Use as well as with OP Care Plans.
  • Surveys: The Surveys tab documents surveys.
  • Vital Signs: The Vital Signs tab documents the Primary and Secondary Vital Signs for the patient as well as the Growth Measurements.
  • Development: The Development tab lists documented developmental milestones.  Developmental milestones can be documented in a narrative or graphic chronology.
  • Detailed Exam: The Detailed Exam tab documents the findings of the preventive exam. You can add or modify information in this tab.
  • Narr Exam: The Narrative Exam provides a narrative of the exam.  Phrase Construction can be used to assist with the creation of the narrative.
  • School Exam: The School Exam tab documents the patient’s visit results for school.
  • Graphic: The Graphics tab links scanned items to an encounter.
  • AG/Counseling: The AG/Counseling tab displays any counseling and anticipatory guidance notes.
  • Diag Tests: The diagnostic tests tab displays, adds, and modifies the diagnostic tests for the preventive exam.
  • Assess/Plan: The Assess/Plan tab codes the visit with diagnosis codes, adds/modifies the plan and patient instructions for the encounter, and allows for orders to be created.
  • Coding: The Coding tab establishes the correct CPT codes for the encounter.
  • Summary: The Summary tab displays the encounter note for the visit.  Review the encounter note in this tab before finalizing the encounter.

2

Care Plans tabThe Care Plans tab lists, prints, and manages care plans. For a patient’s health maintenance schedule.

3

Prior Well Visits tabThe Prior Well Visits tab provides a log of the previous patient well visits.  You can open previous encounters and apply a note or exam to the current encounter. 

4

Templates tabTemplates are pre-written notes you can use in an encounter. Included with your installation of Office Practicum are Pediatric specific templates. The Templates tab edits encounter templates and adds encounter templates to the current note.