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: History
Path: Clinical, Practice Management, or Billing tab > Patient Chart button > Well Visits > New or Open Note button > History
The History window documents a patient’s history. The Patient History captures and displays multiple sections of the patient's history (Past Medical, Family History, Social History, and Perinatal History) in a simple-to-use and easy-to-read format. This section of the Well Visit Note is chart-driven, meaning that the information populated here is pulled from and pushed back to the same section in the Patient Chart.
Well Visit: History Map
Number | Section | Description |
1 | History button | The History button accesses the History 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 a Well Visit Note as unfinished. |
4 | History tabs | The history tabs documents or reviews based on the historical note categories:
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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 | 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:
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2 | Care Plans tab | The Care Plans tab lists, prints, and manages care plans for a patient’s health maintenance schedule. |
3 | Visit Date | The Visit date field indicates the date that the patient preventive exam occurred. |
4 | Prior Well Visits tab | The 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 buttons | The Function buttons delete an entire well visit note, edit a well visit note, or save an well visit note. |
7 | Flag as Incomplete checkbox | The Flag as Incomplete checkbox will mark a well visit as unfinished. |
8 | History tabs | The history tabs documents or reviews based on the historical note categories:
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