Preventive Exam: Detailed Exam

Version 14.8

About Preventive Exam: Detailed Exam Tab

Path: Smart Toolbar > Chart button > Well Visits tab > Open Note button > Detailed Exam tab
Path: Smart Toolbar > Schedule Button > Well Visit tab >  Edit button > Detailed Exam 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 Detailed Exam tab documents the findings of the preventive exam. You can add or modify information in this tab.

Preventive Exam: Detailed Exam 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 buttonsThe 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.
Detailed Exam gridThe Detail Exam grid documents the findings of the exam.  The grid is split into groups (Constitutional, Eyes, Neck, Respiratory, etc).  Within each group is a set of examination points to document.  You can list examination point as Normal (NL), Abnormal (ABNL), and Skip.  The Findings column is a text box where you can input your conclusions.  
Custom Question
The Custom Question field adds a custom examination point to a selected group in Detailed Exam grid.