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We are currently updating the OP Help Center content for the release of OP 20. OP 20 (official version 20.0.x) is the certified, 2015 Edition, version of the Office Practicum software. This is displayed in your software (Help tab > About) and in the Help Center tab labeled Version 20.0. We appreciate your patience as we continue to update all of our content.

Well Visit: Vital Signs and Growth Measurements

Version 14.19

About Well Visit: Vital Signs

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

The Well Visit window charts a patient well-visit exam. The Well Visit window helps to code and complete a preventive encounter visit.  The Well Visit 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 Vital Signs window documents the Primary and Secondary Vital Signs for the patient as well as the Growth Measurements. The Vital Signs and Growth Chart tabs contain the date/time and result of all vital sign and growth measurements in a patient's chart.

BP Reference = latest NHLBI guidelines, Other Vital Sign Reference = Harriet Lane

Well Visit: Vital Signs Map

Number
SectionDescription

1

Vitals/Growth buttonThe Vitals/Growth button opens the Vital Signs and Growth Measurements window ins 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
Vital Signs and Growth Measurement Tabs
  • The Enter Vital Signs tab contains fields for entry of the patient's vitals and growth measurements. 
  • The Growth Charts tab maps the results of the patient’s growth include weight, length, height, head circumference, and the calculated BMI graphs. The curves are based on data from the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion, 2000.
  • The Growth Measurements tab displays the current and previous growth measurements.  These measurements can be excluded from the growth chart by clicking the Exclude checkbox.
  • The Vital Signs Charts tab maps the patients vitals over time including tanner stage, peak flow, pain severity, respiratory rate, temperature, pulse, pulse oximetry,  blood pressure, weight, height, and BMI.
5
Function buttons
The function buttons are used to add a record, edit a record, save a record, cancel a record, and refresh a record.
Version 14.10

About Preventive Exam: Vital Signs Tab

Path: Smart Toolbar > Chart button > Well Visits tab > Open Note button > Vital Signs tab
Path: Smart Toolbar > Schedule Button > Well Visit tab >  Edit button > Vital Signs 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 Vital Signs tab documents the Primary and Secondary Vital Signs for the patient as well as the Growth Measurements. The Vital Signs and Growth Chart tabs contain the date/time and result of all vital sign and growth measurements in a patient's chart.

Preventive Exam: Vital Signs 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
Vital Signs and Growth Measurement Tabs
  • The Enter Vital Signs tab contains fields for entry of the patient's vitals and growth measurements. 
  • The Growth Charts tab maps the results of the patient’s growth include weight, length, height, head circumference, and the calculated BMI graphs. The curves are based on data from the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion, 2000.
  • The Growth Measurements tab displays the current and previous growth measurements.  These measurements can be excluded from the growth chart by clicking the Exclude checkbox.
  • The Vital Signs Charts tab maps the patients vitals over time including tanner stage, peak flow, pain severity, respiratory rate, temperature, pulse, pulse oximetry,  blood pressure, weight, height, and BMI.

3

Care Plans tabThe Care Plans tab lists, prints, and manages care plans for a patient’s health maintenance schedule.
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
Flag as Incomplete checkboxThe Flag as Incomplete checkbox will mark a well visit as unfinished.
7
Function buttonsThe function buttons are used to add a record, edit a record, save a record, cancel a record, and refresh a record.
8
Primary Vitals tabThe Primary Vitals tab fields include blood pressure, pulse, respiratory rate, temperature. Normative values for blood pressure are calculated according to age, sex, and height using reference data from the National Heart, Lung and Blood Institute.
9
Secondary Vitals tabThe Secondary Vitals tab contains pulse oximetry readings, peak flows, pain severity, and other pulmonary function tests.
10
Growth Measurements tabThe Growth Measurements tab contains the date, patient age, stature, weight, BMI, and Comments on measurements.