Preventive Exam: Assessment and Plan

Version 14.8

About Preventive Exam: Assess/Plan Tab

Path: Smart Toolbar > Chart button > Well Visits tab > Open Note button > Assess/Plan tab
Path: Smart Toolbar > Schedule Button > Well Visit tab >  Edit button > Assess/Plan tab

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.

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.  It also includes the Order Worksheet, allowing you to place lab orders, medication orders, patient education, surveys, and follow up visits.

Preventive Exam: Assess/Plan Tab Map

Well Visit Note Editor tab

The Well Visit Note Editor documents the patient preventive exam.  The Well Visit 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.
Prior Well Visits tab
The Prior Well Visits tab lists the previous preventive exam notes.
Templates tab

The Templates tab lists the templates that are created, edited, and reviewed in the Well Visit Template Editor. Templates are pre-written scenarios you can use in a well visit 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 well visit note, edit a well visit note, or save an well visit note.
Flag as Incomplete checkbox
The Flag as Incomplete checkbox will mark a well visit as unfinished.
Diagnoses panel
The Diagnoses panel manages diagnoses codes for the patient encounter.  Use the function buttons in the panel to insert, delete, edit, change sort numbers, add a diagnosis to the problem list and save a diagnosis record.  
Plan/Patient Instruction panel
The Plan and Patient Instruction panel text box provide notes to the plan (solution) and patient instructions.  The notes in this text box will appear based upon the Plan/Patient Instruction radio button selections.
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.
Plan/Patient Instruction radio buttons
The Plan and Patient Instruction radio buttons are used to toggle between the notes inside the Plan or Patient Instruction text box.  Selecting Plan will display the Plan notes in the text box.  Selecting Patient Instruction will display the note inside the patient instructions text box.
Patient Education Given checkbox
The patient education given checkbox provides an indication that the patient was provided with the proper instruction for the reason of the patient encounter visit and the solution to resolve the diagnostic assessment.  
Copy button
The Copy button copies the text in the plan notes and pastes the notes in the patient instructions text box. This will erase any pre-existing text and replace with the Plan text.
Order Worksheet
The Order Worksheet assigns tasks to departments within the practice. Tasks can be associated to an encounter or well-visit template and automatically populate the Order Worksheet.  Tasks can also be assigned through each of the tabs located on the Order Worksheet.
  • : The Order Worksheet Summary tab displays the tasks/orders with their corresponding special instructions, diagnosis, CPT codes, date, and status.
  •  : The Medication Entry tab allows you to create, add, refill, print, send and review prescriptions from this location.
  • : The Diagnostic Test and Lab Entry tab is where you can add a diagnostic test, create a diagnostic test order, modify an order, and perform a diagnostic/test requisition from this location.
  •  : The Immunization tab allows you to create and modify tasks for immunizations in this location.  Clicking the needle icon accesses the patient’s immunization chart.   Recommended vaccines are indicated at the bottom of the order worksheet.
  • : The Patient Education tab allows you to create, modify, and view resource/handout orders from this location.
  •  : The Survey tab allows you to create, modify, and administer survey orders from this location.  Clicking the Do Now button opens the Survey window.
  •  : The Follow Up Task tab allows you to create and modify follow up orders, and select to schedule a followup from this location.  Clicking the Do Now button opens the Schedule and Practice Workflow window
  •  : The Other Task tab is where you can add a referral letter, create tasks for miscellaneous activity, modify a task, and perform tasks from this location.  Clicking the Add Referral Letter button opens the Referral/Care Transaction Details window.
Order Worksheet Task buttons
The Order Worksheet Task buttons are used to:
  •  : Delete a task, remove highlighted order.
  • : Save and assign tasks.  Creates a checklist of tasks for the current tab.
Do Now button
The Do Now button performs the selected task.