Well Visit: Detail Exam

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 Well Visit: Detail Exam

Path: Clinical, Practice Management, or Billing tab > Patient Chart button > Well Visits > New or Open Note button > Detail Exam

The Detail Exam window documents the findings of the Well Visit exam. You can add or modify information in this tab.

Well Visit: Detail Exam Map

Number
SectionDescription

1

Detail Exam buttonThe Detail Exam button accesses the Detail Exam window in the patient's Well Visit Note.
2
Well Visit Function buttons
The function buttons delete an entire Well Visit Note, edit a Well Visit Note, or save a Well Visit Note.
3
Flag as Incomplete checkbox
The Flag as Incomplete checkbox marks the Well Visit Note as unfinished.
4
Detailed Exam grid
The 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 points as Normal (NL), Abnormal (ABNL), and Skip. The Findings column is a text box where you can input your conclusions.
5
Custom Question
The Custom Question field adds a custom examination point to a selected group in the Detailed Exam grid.
Version 14.10

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

Number
SectionDescription

1

Well Visit Note Editor tab

The Well Visit Note Editor documents the patient preventive exam.  The Well Visit Note Editor contains the following tabs:


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 lists the previous preventive exam notes.

4

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.

5
Function buttonsThe Function buttons delete an entire well visit note, edit a well visit note, or save an well visit note.
6
Flag as Incomplete checkboxThe Flag as Incomplete checkbox will mark a well visit as unfinished.
7
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.  
8
Custom QuestionThe Custom Question field adds a custom examination point to a selected group in Detailed Exam grid.