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: Interval History
Path: Clinical, Practice Management, or Billing tab > Patient Chart button > Well Visits > New or Open Note button > Interval Hx
The Interval History section of the Well Visit is used to document the patient’s interval history and review of systems. Phrase Construction is available in the Interval History field.
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. |
Well Visit: Interval History Map
Number | Section | Description |
1 | Interval Hx button | The Interval Hx button accesses the Interval 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 the Well Visit Note as unfinished. |
4 | Phrase Construction button | The Phrase Construction button opens the Phrase Construction window. Phrase Constriction assists with entering into the Interval History text field. |
5 | Interval History | The Interval History text field is used to document significant occurrences between the current visit and the last visit with the Provider. This is a free text field that can be edited. |
6 | Review of Systems (ROS) | The ROS fields are where the assessment and documentation of the visit are entered. The patient's symptoms/questions are grouped by Well Visit type. Under each group are various questions/symptoms where 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. |
7 | Custom Question | The Custom Question field adds a custom question to a selected category in the Review of Systems. |
Version 14.10
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
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 | 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. |
3 | Care Plans tab | The Care Plans tab lists, prints, and manages care plans for a patient’s health maintenance schedule. |
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 preventive exam as unfinished. |
8 | 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. |
9 | 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. |
10 | Custom Question | The Custom Question field adds a custom question to a selected category in Review of Systems. |
