Preventive exam templates

From OfficePracticum Help

Jump to: navigation, search

You can use templates during routine well visits and some sick visits to load standard information into your Preventive Exam note. Preventive Exam templates are tailored to a specific age group, visit type and some chronic diseases. The templates include Review of Systems questions, anticipatory guidance, an assessment and plan and any applicable ICD-9 codes.

NOTE: When updating to a new version of Office Practicum, be sure to update your age-based preventive exam templates, to ensure that new Review of Systems questions will be displayed when a well child template is loaded.

Contents

[edit] Opening & viewing

  1. Press F8 to open the Patient Chart, then choose a patient.
  2. Click the ExamComp button to open the Preventive Exam form.
  3. Click the Templates tab in the left-hand column. A list of prefigured templates will appear. The first are the standard age-based templates for well visits, followed by templates specialized to certain visit types or chronic diseases. The detailed exam templates can also be filtered by sex.
  4. To view a template, double-click its title in the list. The template will expand to full view in a new Edit Template window.
  5. The Edit Template window contains three windows accessed by a row of tabs on the left side - P. Exam, ROS and Exam.

[edit] Applying a Preventive Exam template

  1. Open a Preventive Exam note by opening the patient's F8 chart and clicking the ExamComp or Exam button in the central column.
  2. Click the Templates tab in the column on the left. The Template Grid will appear.
  3. The Template Grid lists groups of templates organized according to body system. Double-click on any system name, or single-click on the Image:Add.jpg button to the immediate left of the system name. The templates in that system will be listed alphabetically below the name.
  4. To search for a specific template, type the name of the template in the search field at the top. As you begin typing the name, the system will automatically search for and highlight the appropriate template.
  5. Click to highlight the name of the template you wish to use.
  6. Once the name of the desired template is highlighted, click the small apply button in the column to the immediate left of the template name. The contents of the template will be applied to the text fields of your note.
  7. Add any additional information or modifications for the specific patient.

[edit] Saving a well visit note as a template

Please see Saving an encounter note as a template. These instructions are the same for both the Patient Encounter Note and the Well Exam/Preventive Exam note.

[edit] Modifying Preventive Exam templates

[edit] Modifying content in a Preventive Exam template

  1. Open the Templates tab and double-click on the template to be modified.
  2. With the P. Exam window open in the Edit Template window, click the Image:Edit.jpg button in the tool bar at the top of the new window, and make desired revisions in the fields.
  3. When finished, click the Image:Check.jpg button in the tool bar to save your changes.
    NOTE: If you revise the templates for well visits, do not change the template name. If you do, the template will no longer be recognized and will not be able to load into a preventive exam note.

[edit] Modifying Review of Systems questions in Preventive Exam templates

Age-based Preventive Exam templates can be set to display certain Review of Systems questions and not others. The Teen Visit and Psychiatric ROS questions, for example, can appear for teenagers but are not pertinent to younger children.

[edit] Adding/removing Review of Systems questionnaires from a Preventive Exam template

  1. Open the Preventive Exam form by clicking the ExamComp or Exam button in the central column of the F8 Patient Chart.
  2. A pop-up window will prompt you to confirm as follows: "Do you wish to use the default template for age?" Click Yes.
  3. Click the Templates tab in the left column. The list of age-based templates will appear.
  4. Double-click on the desired template. It will expand for viewing in a new window.
  5. Click the ROS tab in the new window (tabs are lined up on the left side) to display the Review of Systems panels assigned to this particular template.
  6. To add a new panel, click the Image:Down Arrow.jpg box under Select a Group to Add/Replace or Delete and select a Review of Systems name from the drop-down menu.
  7. Click the Add or Replace the Selected Group button on the right.
  8. The chosen Review of Systems will now be included in the default template for the chosen age group.

[edit] Modifying and/or customizing Review of Systems questionnaires

See Customizing Review of Systems for instructions.

[edit] Creating a specialized Preventive Exam template

You can create a Preventive Exam template for a specific disease or condition by saving your encounter note as a template.

  1. After entering your findings in a preventive exam note, click the Templates tab.
  2. Click the Image:Ellipses.jpg button labeled Save Encounter as Template.
  3. A pop-up window will prompt you to enter a name for the template. Type a name in the field and click OK.
  4. These specialized templates will appear in the grid list of templates following after those for the standard pediatric visits.

[edit] Importing/exporting templates

Encounter note templates can be shared with others through importing and exporting. Please see Importing/exporting templates for details.

[edit] Helpful hints

  • To create a specialized template for an individual patient with multiple physical conditions (e.g., the Vater syndrome), save the template under the child's name, and use this template during the patient's future visits.
  • A template for a child with cystic fibrosis would focus on pertinent negatives. Since the fields in this form are only 10 characters long, you would need to use consistent abbreviations. For example, to indicate that there is no wheezing, rales or retractions, you could use the abbreviation "w/r/r". You can enter more detailed information, such as chest diameter impressions, in the patient's Preventive Exam note.

[edit] Troubleshooting/Questions

[edit] Why are my templates defaulting to 1 month regardless of what age the patient is?

You must edit the age in months for each template to fix this problem:

  1. Press F8 to access the Patient Chart.
  2. Choose the patient.
  3. Click Well Exam.
  4. Click on the Templates tab.
  5. For each template defaulting to 1 month, click on the Edit button to the left of the template name to open the template for editing.
  6. At the top of the template editing form, enter the correct number of months for the template in the Min Age (months) field.
  7. Click the checkmark button in the toolbar at the top of the form to save.
  8. When finished, open a Preventive Exam form again.
  9. A pop-up message will prompt you, "Do you wish to apply the Default template for age?" Click Yes, and the appropriate template should load.

[edit] See also

Views
Personal tools