Recording Reason for Visit Information

Here's how to open the Reason for Visit window:

1. Within an open exam, click the Chief Complaint tab on the ExamWRITER chart window.
2. Click the Reason for Visit bar.

   The Reason for Visit window opens.

If you conduct telehealth visits or see patients at a facility outside of your office, you can indicate the setting in the Visit Location drop-down menu:

1. Open the Reason for Visit window. To learn how, go to Opening the Reason for Visit Window.
2. Click the Visit Location drop-down menu and select a location.

   The default location is office. Office and telehealth visits trigger the 2021 E/M coding guidelines. All other settings trigger the 1997 E/M coding guidelines. The Quick Code window available in the exam is controlled by the Visit Location drop-down menu.

3. Click Process or right-click anywhere in the Reason for Visit window when you're finished editing the visit information.

If a technician conducts the patient through pretesting or a scribe documents an exam performed by a doctor, you can document who the technician or scribe was in the Reason for Visit window:

1. Open the Reason for Visit window. See Opening the Reason for Visit Window.
2. Click the Exam Technician/Scribe drop-down list, and select a name from the list.

   The Exam Technician/Scribe drop-down is populated from the OfficeMate list of staff.

3. Click Process or right-click anywhere in the Reason for Visit window when you're finished editing the visit information.

Document the patient's physicians and referral as needed:

1. Open the Reason for Visit window. To learn how, go to Opening the Reason for Visit Window.
2. Click the ... (ellipse) next to the Primary Care Physician text box to open the Primary Care Physician window and double-click the primary care physician.

   To add a new primary care physician to the Primary Care Physician window, click New and go to Setting Up Correspondent Information.

3. Click the ... (ellipse) next to the Other Physician text box to open the Other Doctor window and double-click the other physician.

   To add a new physician to the Other Doctor window, click New and go to Setting Up Correspondent Information for more information.

4. As needed, indicating a referring provider in OfficeMate, select the PCP (primary care physician), Other Physician, or None radio button in the Referred by box.
5. Click Process or right-click anywhere in the Reason for Visit window when you're finished editing the visit information.

Document the patient's physicians and referral as needed:

1. Open the Reason for Visit window. To learn how, go to Opening the Reason for Visit Window.
2. Double-click the exam type(s) in the Exam type table to add them to the Selected Exam Types table.
   • You can select only six exam types (i.e., procedures) to add to the Select Exam Types box.
   • To remove an exam type from the Selected Exam Types box, select the exam type and click the Remove Item arrow.
   • To rearrange the exam types in the Selected Exam Types box, click the arrows to the left of the table. You can move exam types up or down one row at a time, move an exam type to the top of the list to make it the primary exam type (click the Make Primary arrow), or move an exam type to the bottom of the list.
3. Click Process or right-click anywhere in the Reason for Visit window when you're finished editing the visit information.

You can review and edit such information as patient occupation, last visit date, last physical exam date, and order dates. You can also add general notes about the nature of the exam. Here's how:

1. Open the Reason for Visit window. To learn how, go to Opening the Reason for Visit Window.
2. Add general, prewritten notes to the visit as needed:
   1. Click your cursor in the Notes text box.
   2. A drop-down appears listing available notes.
   3. Left-click individual notes to add them to the visit.
   4. Right-click when you're finished to close the drop-down.

      To select multiple notes, left-click to select multiple notes. After you have selected all of the patient’s notes, right-click to insert the notes into the text box.

3. Click the Occupation drop-down menu and select the patient’s occupation.

   To search for occupations in the Occupation field, click the drop-down arrow in the Occupation field, place your cursor in the text box, and type the first letter of the occupation. The drop-down menu advances to the occupations beginning with the letter that you typed in the text box.

4. Type or select the patient’s last office visit date in the Last Office Visit text box.
5. Type or select the patient’s last physical exam date in the Last Physical Exam text box.
6. If the patient completed his or her last eye exam at another practice, select the time period when the patient had his or her last eye exam from the Last Eye Exam(elsewhere) drop-down menu.
7. Click Process or right-click anywhere in the Reason for Visit window when you're finished editing the visit information.