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: Vital Signs

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

The Vital Signs window in an Encounter Note documents the Vital Signs and Growth Measurements for the patient as recorded during their visit. This section of the Encounter Note is chart-driven, meaning that the information populated here is pulled from and pushed back to the same section in the Patient Chart. BP Reference = latest NHLBI guidelines; Other Vital Sign Reference = Harriet Lane.

Well Visit: Vital Signs Map

Number	Section	Description
1	Vitals/Growth button	The Vitals/Growth button accesses the Vital Signs and Growth Measurements window ins 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	Vital Signs and Growth Measurement Tabs	The Enter Vital Signs tab contains fields for entry of the patient's vitals and growth measurements. Vital Signs taken for the current date will be highlighted. 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. The measurement taken for the current date will be highlighted. These measurements can be excluded from the growth chart by clicking the Exclude checkbox. The Vital Signs Charts tab maps the patient's 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	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: Visit Info Interval Hx Problem List Allergy/Rxn Med Review Immunizations History Risk Assess Surveys Vital Signs Development Detailed Exam School Exam Graphic AG/Counseling Diag Tests Assess/Plan Coding Summary
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 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	Flag as Incomplete checkbox	The Flag as Incomplete checkbox will mark a well visit as unfinished.
7	Function buttons	The function buttons are used to add a record, edit a record, save a record, cancel a record, and refresh a record.
8	Primary Vitals tab	The 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 tab	The Secondary Vitals tab contains pulse oximetry readings, peak flows, pain severity, and other pulmonary function tests.
10	Growth Measurements tab	The Growth Measurements tab contains the date, patient age, stature, weight, BMI, and Comments on measurements.

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