Assessment and Plan

Version 14.8

Overview

This section will introduce the users to the steps required to code a visit with diagnosis codes. 

  1. Diagnosis code(s) for the visit are listed in the Diagnosis section of the Assess/Plan window.

  1. To add or modify ICD codes, follow the steps below. 
  1. Begin typing the name or code of the diagnosis code.
  2. Press the Enter key. The ICD window will display.
  3. Click to select a code.

or

  1. If the code is not found: 
  2. Click the Full Search button. The ICD Code table displays.
  3. If the ICD Code is not visible, use the radio buttons on the window to expand the search.

  1. Click on the Post Edit  button to save the diagnosis codes.
  2. Verify that the Plan and Patient Instructions are correct and make any necessary changes.
  3. If doing Meaningful Use, place a check mark in the Patient Education Given check box.