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Chapter 6

The Office Visit

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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

Chapter 6 Content

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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

Chapter 6 Key Terms

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LO 6.1 Components of the Office Visit

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• 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

Office Visit

LO 6.1

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SOAP Note

LO 6.1

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LO 6.2 Building an Office Visit Note

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• 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

Building an Office Visit

LO 6.2

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• 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

Chief Complaint, Present Illness, Review of Systems, and Exam tabs

LO 6.2

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• Allows for any item or all items from the Face Sheet to be inserted into the OV Note

Face Sheet tab

LO 6.2

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• 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

Vitals tab

LO 6.2

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• 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

Diagnosis tab

LO 6.2

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• 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

Prescriptions tab

LO 6.2

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• 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

Tests tab

LO 6.2

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• Procedures are selected by choosing the appropriate category

• Manual, unique notes can be added

Procedures tab

LO 6.2

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• Includes– Counseling– Coordination of Care

• Previous entries can be copied and reused

Other Treatment tab

LO 6.2

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• Select a Follow-Up period• Set up reminders and referral notes• Pop-up text can be used

Follow-Up tab

LO 6.2

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• Provider must either initial or sign and lock the OV Note

• Initial Only allows it to be called up later and revised

Signing and Dating an OV Note

LO 6.2

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LO 6.3 Activities within the Office Visit Screen

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• 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

Activities within the Office Visit Screen

LO 6.3

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LO 6.4 Routing Slip

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• 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

Routing Slip

LO 6.4

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LO 6.5 Adding Addenda to an Office Visit Note

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• 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

Adding an Addendum to an Office Visit Note

LO 6.5

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LO 6.6 Office Visit Reports

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• 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

Office Visit Reports

LO 6.6

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• Creating an OV Report Template• Editing an OV Report Template• Using an OV Report

Office Visit Template Report

LO 6.6

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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

Chapter 6 Summary

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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

Chapter 6 Summary

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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

Chapter 6 Summary

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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

Chapter 6 Summary

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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

Chapter 6 Summary

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LO 6.6 Create various office visit reports• Report to patient• Office Visit Note• H&P Report• OV Template Report

Chapter 6 Summary