About Preventive Exam: Interval Hx Tab
Path: Smart Toolbar > Chart button > Well Visits tab > Open Note > Internal Hx tab
Path: Smart Toolbar > Schedule Button > Well Visit tab > Edit button > Interval Hx 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 Interval Hx tab documents the patient’s interval history and review of systems. You can use the Phrase Construction map if needed.
|Note: A preventive exam/well visit note in Office Practicum is divided into sections which include interval history (e.g. parental concerns, nutrition check), a developmental screening, an exam, anticipatory guidance/counseling, screening tests, etc.|
Each Pediatric practice determines which portions of the exam the clinical staff completes.
Preventive Exam: Interval Hx 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:
|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.|
|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.|
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 preventive exam as unfinished.|
|Interval History||The Interval History text box explains what happened to a patient between the current visit and the last visit to the doctor. You can free Type in the box. You can also delete any text from the box. The Phrase Constriction button assists with helping create the text string with Interval History text box.|
|Review of Systems (ROS)||The ROS fields is where you can assess and document the patient's symptoms/questions grouped by well visit type. Under each well visit group, various symptoms and questions are listed which you can mark as 'Confirms', 'Denies', 'Skip', or leave as 'Pertinent'. Anything marked 'Confirm' or 'Denies' will be part of the final note. Anything left as 'Pert' (pertinent) will not be part of the final note.|
|Custom Question||The Custom Question field adds a custom question to a selected category in Review of Systems.|