Preventive Exam: History

Version 14.19

About Preventive Exam: History

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

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 history window documents a patient’s past medical history, family history, social history, and perinatal history.

Preventive Exam: History Map

Number
SectionDescription

1

History buttonThe History button opens the History window in the patient's well visit note.

2

Well Visit Function buttonsThe function buttons delete an entire well visit note, edit a well visit note, or save an well visit note.
3
Flag as Incomplete checkboxThe Flag as Incomplete checkbox will mark an encounter as unfinished.
4
History tabs
The history tabs documents or reviews based on the historical note categories:
  • Past Medical History: The Past Medical History tab documents or reviews a patient’s past medical history. You can link or add history to the Problem list from this area.
  • Family History: The Family History tab documents or reviews a patient’s family medical history. Family members are linked based upon how they are documented in the Contacts field.
  • Social History: The Social History tab documents a patient’s social history such as pets, smokers in the home, siblings, visitation status, etc.
  • Perinatal History: The Perinatal History tab documents notes for newborn history, birth info, neonatal course, and maternal/pregnancy history.
Version 14.9

About Preventive Exam: History Tab

Path: Smart Toolbar > Chart button > Well Visits tab > Open Note button > History tab
Path: Smart Toolbar > Schedule Button > Well Visit tab >  Edit button > History 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 history tab documents a patient’s past medical history, family history, social history, and perinatal history.

Preventive Exam: History 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
Visit DateThe Visit date field indicates the date that the patient preventive exam occurred.
4
Prior Well Visits tabThe Prior Well Visits tab lists the previous  preventive exam notes.

5

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.

6
Function buttonsThe Function buttons delete an entire well visit note, edit a well visit note, or save an well visit note.
7
Flag as Incomplete checkboxThe Flag as Incomplete checkbox will mark a well visit as unfinished.
8
History tabsThe history tabs documents or reviews based on the historical note categories:
  • Past Medical History: The Past Medical History tab documents or reviews a patient’s past medical history. You can link or add history to the Problem list from this area.
  • Family History: The Family History tab documents or reviews a patient’s family medical history. Family members are linked based upon how they are documented in the Contacts field.
  • Social History: The Social History tab documents a patient’s social history such as pets, smokers in the home, siblings, visitation status, etc.
  • Perinatal History: The Perinatal History tab documents notes for newborn history, birth info, neonatal course, and maternal/pregnancy history.