© 2013 The McGraw-Hill Companies, Inc. All rights reserved. Chapter 6 The Office Visit

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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

© 2013 The McGraw-Hill Companies, Inc. All rights reserved. 6-3 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

© 2013 The McGraw-Hill Companies, Inc. All rights reserved. 6-4 LO 6.1 Components of the Office Visit

© 2013 The McGraw-Hill Companies, Inc. All rights reserved. 6-5 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

© 2013 The McGraw-Hill Companies, Inc. All rights reserved. 6-6 SOAP Note LO 6.1 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.

© 2013 The McGraw-Hill Companies, Inc. All rights reserved. 6-7 LO 6.2 Building an Office Visit Note

© 2013 The McGraw-Hill Companies, Inc. All rights reserved. 6-8 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

© 2013 The McGraw-Hill Companies, Inc. All rights reserved. 6-9 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

© 2013 The McGraw-Hill Companies, Inc. All rights reserved Allows for any item or all items from the Face Sheet to be inserted into the OV Note Face Sheet tab LO 6.2

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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

© 2013 The McGraw-Hill Companies, Inc. All rights reserved Procedures are selected by choosing the appropriate category Manual, unique notes can be added Procedures tab LO 6.2

© 2013 The McGraw-Hill Companies, Inc. All rights reserved Includes – Counseling – Coordination of Care Previous entries can be copied and reused Other Treatment tab LO 6.2

© 2013 The McGraw-Hill Companies, Inc. All rights reserved Select a Follow-Up period Set up reminders and referral notes Pop-up text can be used Follow-Up tab LO 6.2

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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

© 2013 The McGraw-Hill Companies, Inc. All rights reserved LO 6.3 Activities within the Office Visit Screen

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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

© 2013 The McGraw-Hill Companies, Inc. All rights reserved LO 6.4 Routing Slip

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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

© 2013 The McGraw-Hill Companies, Inc. All rights reserved LO 6.5 Adding Addenda to an Office Visit Note

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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

© 2013 The McGraw-Hill Companies, Inc. All rights reserved LO 6.6 Office Visit Reports

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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

© 2013 The McGraw-Hill Companies, Inc. All rights reserved Creating an OV Report Template Editing an OV Report Template Using an OV Report Office Visit Template Report LO 6.6

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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

© 2013 The McGraw-Hill Companies, Inc. All rights reserved 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

© 2013 The McGraw-Hill Companies, Inc. All rights reserved LO 6.6 Create various office visit reports Report to patient Office Visit Note H&P Report OV Template Report Chapter 6 Summary