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Using PCE

How to Add or Edit an Exam

When you choose Exam under Update Encounter, you will also be prompted to enter the Topic, Level of Understanding, and Encounter Provider.

NOTE: A Clinical Coordinator can change the items or categories available to choose from for Exams through the PCE Table Maintenance Menu. If you wish to help define the Exam list, check with your Coordinator.

Steps to add an Exam

1. Select UE, from the PCE Appointment List screen.

2. Select XA from the PCE Update Encounter screen.

PCE Update Encounter         Jul 25, 1996 08:24:21       Page:  1 of  1

PCEPATIENT,ONE    000-45-6789           Clinic:  CARDIOLOGY

Encounter Date  07/22/96  11:08         Clinic Stop:  303  CARDIOLOGY

 1 Encounter Date and Time:  JUL 22, 1996@11:08:14

 2 Provider:  PCEPROVIDER,ONE    PRIMARY    ATTENDING

 3 ICD9 Code or Diagnosis:  V70.3     MED EXAM NEC-ADMIN PURP

   Provider Narrative:  OTHER GENERAL MEDICAL EXAMINATION FOR

                        ADMINISTRATIVE PURPOSES

   Primary/Secondary Diagnosis:  PRIMARY

 4 CPT Code:  25066     BIOPSY FOREARM SOFT TISSUES

   CPT Modifier: 22   UNUSUAL PROCEDURAL SERVICES

 5 Education Topic:  VA-TOBACCO USE SCREENING

         + Next Screen   - Prev Screen   ?? More Actions

ED  Edit an Item        TR  Treatment           DD  Display Detail

DE  Delete an Item      IM  Immunization        DB  Display Brief

EN  Encounter           PE  Patient Ed          IN  Check Out Interview

PR  Provider            ST  Skin Test           QU  Quit

DX  Diagnosis (ICD)     XA  Exam

CP  CPT (Procedure)     HF  Health Factors

Select Action: Quit// XA   Exam

3. Respond to the following prompts for Exams, as appropriate.

Exam:  GENERAL EXAM

Results:  ?

Choose from:

A        ABNORMAL

N        NORMAL

Results:  NORMAL

Encounter Provider:  PCEPROVIDER,TEN//[ENTER] PCEPROVIDER,TEN          TP

Comments: [ENTER]

Exam: [ENTER]

4. The edited screen is then displayed.

August 1996PCE V. 1.0 User Manual41

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