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The Office Visit
Chapter 6
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
Chapter 6 Content
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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
© 2013 The McGraw-Hill Companies, Inc. All rights reserved.
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Chapter 6 Key Terms
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Addendum
Body Mass Index (BMI)
Coordination of Care
Evaluation &
Management (E&M)
Code
• E&M Coder
• History & Physical (H&P)
Report
• SOAP
• Review of Systems (ROS)
• Routing Slip
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LO 6.1 Components of
the Office Visit
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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
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SOAP Note
S
• Subjective
• The patient’s current medical condition from the patient’s point of view.
O
• Objective
• The patient’s condition from the practitioner’s perspective.
A
• Assessment
• The physician’s diagnosis(es) based on the objective findings
P
• Plan
• What the physician will do to test and treat the patient’s symptoms.
LO 6.1
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LO 6.2 Building an Office
Visit Note
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Building an Office Visit
• Available tabs:
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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
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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
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Face Sheet tab
• Allows for any item
or all items from
the Face Sheet to
be inserted into
the OV Note
LO 6.2
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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
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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
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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
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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
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Procedures tab
• Procedures are selected
by choosing the
appropriate category
• Manual, unique notes
can be added
LO 6.2
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Other Treatment tab
• Includes
– Counseling
– Coordination of Care
• Previous entries can be copied and reused
LO 6.2
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Follow-Up tab
• Select a Follow-Up period
• Set up reminders and referral notes
• Pop-up text can be used
LO 6.2
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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
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LO 6.3 Activities within
the Office Visit Screen
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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
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LO 6.4 Routing Slip
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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:
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Patient type
Complexity of problem
Level of history reviewed
Extent of exam and ROS
Level of decision-making
LO 6.4
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LO 6.5 Adding Addenda
to an Office Visit Note
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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
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LO 6.6 Office Visit
Reports
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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
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Office Visit Template Report
• Creating an OV Report Template
• Editing an OV Report Template
• Using an OV Report
LO 6.6
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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
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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
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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
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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
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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
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Chapter 6 Summary
LO 6.6 Create various office visit reports
• Report to patient
• Office Visit Note
• H&P Report
• OV Template Report
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