The Office Visit

1. The Office Visit

2. Chapter 6 Content • 6.1 Components of the Office Visit • 6.2 Building an Office Visit Note • 6.3 Activities within the Office Visit Screen • 6.4 Routing Slip • 6.5 Adding Addenda to an Office Visit Note • 6.6 Office Visit Reports

3. Chapter 6 Key Terms • History & Physical (H&P) Report • SOAP • Review of Systems (ROS) • Routing Slip • Addendum • Body Mass Index (BMI) • Coordination of Care • Evaluation & Management (E&M) Code • E&M Coder

4. LO 6.1 Components of the Office Visit

5. Office Visit • An outpatient encounter to receive health advice for a symptom or condition • Available from the New menu on the Patient Chart menu bar and [New OV] button • Three main areas • SOAP note • Face Sheet information • Pop up text and navigation LO 6.1

6. SOAP Note LO 6.1

7. LO 6.2 Building an Office Visit Note

8. Building an Office Visit • Available tabs: • Chief Complaint • History of Present Illness • Review of Systems • Face Sheet • Vitals • Exam • Diagnosis • Prescriptions • Tests • Procedures • Other Treatment • Follow-up/Reminders • Care Tree • Show Chart Summary LO 6.2

9. Chief Complaint, Present Illness, Review of Systems, and Exam tabs • Display notes from previous encounters in the bottom right panel available to copy • Time & Initial Stamp available to document activities • Pop-up Text in each section • Search feature in each tab across the database LO 6.2

10. Face Sheet tab • Allows for any item or all items from the Face Sheet to be inserted into the OV Note LO 6.2

11. Vitals tab • Nine basic vitals • Three additional vitals can be added to server • BMI is automatically calculated upon entry of height and weight • Displays four vital sign charts LO 6.2

12. Diagnosis tab • Choose from PMHX, Problem List, and Previous Dx for rapid entry • Patients are often seen for the same diagnoses, receive the same medications, and undergo the same procedures as previous visits LO 6.2

13. Prescriptions tab • E-prescribing required under HITECH Act • Allows for utilization of Allergies and Sensitivities section • New Prescriptions can be chosen from Routine Medications and Previous Prescriptions • Strength and Dosage can be edited for specific OV Note LO 6.2

14. Tests tab • CPOE documents: • Labs, imaging studies, medical tests, and medication • Tests are ordered from within Office Visit Screen • Can be printed or faxed from the OV note LO 6.2

15. Procedures tab • Procedures are selected by choosing the appropriate category • Manual, unique notes can be added LO 6.2

16. Other Treatment tab • Includes • Counseling • Coordination of Care • Previous entries can be copied and reused LO 6.2

17. Follow-Up tab • Select a Follow-Up period • Set up reminders and referral notes • Pop-up text can be used LO 6.2

18. Signing and Dating an OV Note • Provider must either initial or sign and lock the OV Note • Initial Only allows it to be called up later and revised LO 6.2

19. LO 6.3 Activities within the Office Visit Screen

20. Activities within the Office Visit Screen • Editing the Patient’s Face Sheet • Modifying and Printing the Patient’s Immunization Record • Viewing and Graphing the Patient’s Lab Results • Creating an Excuse Note • Changing the Chart tab LO 6.3

21. LO 6.4 Routing Slip

22. Routing Slip • Creates billable codes from the Office Visit note and Superbill • Provides access to the E&M Coder, which will guide to a E&M Code level • E & M Code based on: • Patient type • Complexity of problem • Level of history reviewed • Extent of exam and ROS • Level of decision-making LO 6.4

23. LO 6.5 Adding Addenda to an Office Visit Note

24. Adding an Addendum to an Office Visit Note • Office Visit Notes can be signed and locked • If the edit button is pushed, • Not Editable box will appear • The option will allow user to add an addendum LO 6.5

25. LO 6.6 Office Visit Reports

26. Office Visit Reports • Examination Report to Patient • Examination reports detail the examination notes of an office visit and include diagnoses, tests, procedures, and prescriptions • Office Visit Note • Printed in SOAP note format • Does not include test results • History & Physical Report (H&P) • Combines patient history such as allergies, current medications, past medical, and more with aspects of the current physical exam and test results LO 6.6

27. Office Visit Template Report • Creating an OV Report Template • Editing an OV Report Template • Using an OV Report LO 6.6

28. Chapter 6 Summary LO 6.1 Describe the components of an office visit note • SOAP Format • Three main panels • Face Sheet • SOAP Note • Pop-up text and navigation

29. Chapter 6 Summary LO 6.2 Create a new office visit note • Navigation tabs • Three ways to enter data • Copy previous encounters • Initial and Time-stamp available • Dx, Px, tests, and medications must be coded • Prescriptions can be printed, faxed, or electronically sent • Drug-drug and drug- allergy checking • Sign and Lock OV notes

30. Chapter 6 Summary LO 6.3 Complete activities in the Office Visit window, including editing the face sheet, modifying the immunization record, viewing a patient’s lab graphs, creating excuse notes, and changing chart tabs • Face Sheet can be edited • Immunization records can be modified and printed • Excuse notes can be created • Stored under Encounters or other customized category

31. Chapter 6 Summary LO 6.4 Create a routing slip • Create a routing slip • Contains all billable items from OV note • E & M code is recommended • Based on notation from OV note or time spent

32. Chapter 6 Summary LO 6.5 Edit an office visit note by adding an addendum • Addenda • Additions to signed and locked OV notes • Added at the bottom of OV note • Auto signed and dated

33. Chapter 6 Summary LO 6.6 Create various office visit reports • Report to patient • Office Visit Note • H&P Report • OV Template Report