Preventive Exam: Summary

Version 14.8

About Preventive Exam: Summary Tab

Path: Smart Toolbar > Chart button > Well Visits tab > Open Note button > Summary tab
Path: Smart Toolbar > Schedule Button > Well Visit tab >  Edit button > Summary 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 Encounter Summary Sheet allows you to review finalized well visit notes.  The notes appears with all the details entered in the previous Well Visit tabs.  You can view the Primary Preventive Exam Note and Patient Exit Note as they were created.

Patient Encounter: Summary Map

Number

Section
Description
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 tab
The Care Plans tab lists, prints, and manages care plans for a patient’s health maintenance schedule.
3
Prior Well Visits tab
The 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

Summary Report Criteria
The Summary Report Criteria selects created Report Criteria in a dropdown list.  Clicking the Edit Criteria button opens the Report Criteria window, where you can create or edit a criteria set.

6

Rebuild Summary
If you would like to Rebuild the Summary for the Alternate Notes tab, select the Summary Report Criteria using the drop down arrow in the Summary Report Criteria and then click Rebuild Summary button.

7

Print buttons
Notes and Letters are printed using the Print Note and Print Letter buttons.
8
Search bar
The Search bar is used to locate specific content in the summary.

9

CDA button
The CDA button will create a CDA for the selected encounter.
10
Notes tab
  • The Primary Encounter Note tab displays the details of the primary encounter note including patient demographics, visit information (date, time and location), chief complaint, history of present illness, ROS findings, medications reviewed, etc.
  • The Patient Exit Note tab displays all the details entered into the patient exit note.
  • The Alternate Notes tab contains any alternate notes that may have been added to the encounter.
11
Note Visibility
The Note Viability dropdown determines who can view the encounter note.   

12

Finalize button
The Finalize button approves and locks a patient encounter note.  Once the note has been finalized it cannot be changed.  After a note has been finalized, open the finalized note and click the Addenda tab.  An addendum can be created, edited, and viewed in the Addenda tab to add information to the encounter note. The user approving the finalized note will appear in the Note Finalized by field.

13

Cosign button
The Cosign button adds a cosigner to the patient encounter note after a note has been finalized.  The logged in user name clicking the Cosign button will appear in the Note Cosigned by field.

14

Save Template button
The Save Template button saves any changes to the template and closes the summary sheet.