Patient Encounter: Assess/Plan

Version 20.10

About Patient Encounter: Assess/Plan

Path: Clinical, Practice Management, or Billing tab > Patient Chart button > Encounter > New or Open Note button > Assess/Plan

The Assess/Plan window codes the visit with diagnosis codes, adds the assessment of the diagnosis, and adds/modifies the plan and patient instructions for the Encounter. 

Patient Encounter: Assess/Plan Map

Number
SectionDescription
1
Assess/Plan buttonThe Assess/Plan button opens the Assessment/Plan window in the patient's encounter note.
2
Encounter Function buttonsThe Function buttons delete an entire encounter note, edit an encounter note, or save an encounter note.
3
Flag as Incomplete checkboxThe Flag as Incomplete checkbox will mark an encounter as unfinished.
4
All TemplatesThe All Templates field is used to select an encounter template that was created or edited in the Encounter Template Editor.  Predefined information will appear in the encounter when a template is selected.
5Complete List button
The Complete List button provides a complete list of encounter templates.
6Prior Notes button
The Prior Notes button views prior notes and messages for the selected patient.
7
Diagnoses panelThe Diagnoses panel manages diagnoses codes for the patient encounter. Use the function buttons in the panel to insert, delete, edit, change sort numbers, add to problem list and save a patient encounter diagnosis record. This panel also includes the options to Auto-calculate BMI and Auto-create patient education to automatically create a task for a handout and send it to the patient portal.
8
Assessment panel
The Assessment panel is used to provide assessment notes to the diagnosis for the patient encounter. This panel also includes a Phrase Construction button  and the Diagnostic Test Reviewed checkbox to add an indication into the Assessment text box that a Diagnostic Test was reviewed.
9
Plan panelThe Plan panel text box provides notes to the plan (solution). The notes in this text box are displayed based on the template chosen. A Phrase Construction button is also available in this panel.
10
Patient Instruction panelThe Patient Instruction panel is used to include patient instruction given to the patient. The notes in this text box are displayed based on the template chosen. This panel also include a Phrase Construction button and the Patient education given checkbox to add an indication that the patient was provided with the proper instruction for the reason of the patient encounter visit and the solution to resolve the diagnostic assessment. 
Version 20.8

About Patient Encounter: Assessment

Path: Clinical, Practice Management, or Billing tab > Patient Chart button > Encounter > New or Open Note button > Assessment

The Patient Encounter helps to code and complete an encounter visit. The encounter note encompasses both narrative and comprehensive formats. It also allows you to customize the layout of the note. The note is added to the patient chart.

The Assessment window codes the visit with diagnostic codes, and adds/modifies the plan and patient instructions for the encounter. It also includes the Order Worksheet, allowing you to place lab orders, medication orders, patient education, surveys, and follow up visits.

Patient Encounter: Assessment Map

Number
SectionDescription
1
Assessment buttonThe Assessment button opens the Assessment window in the patient's encounter note.
2
Encounter Function buttonsThe Function buttons delete an entire encounter note, edit an encounter note, or save an encounter note.
3
Flag as Incomplete checkboxThe Flag as Incomplete checkbox will mark an encounter as unfinished.
4
All TemplatesThe All Templates field is used to select an encounter template that was created or edited in the Encounter Template Editor.  Predefined information will appear in the encounter when a template is selected.
5
Phrase Construction buttonThe Phrase Construction button opens the Phrase Construction window.  Phrase Construction assists with the creation of notes and other text-based descriptions.
6
Diagnoses panelThe Diagnoses panel manages diagnoses codes for the patient encounter.  Use the function buttons in the panel to insert, delete, edit, change sort numbers, add to problem list and save a patient encounter diagnosis record. 
7
Complete List buttonThe Complete List button provides a complete list of encounter templates.
8
Prior Notes buttonThe Prior Notes button views prior notes and messages for the selected patient.
9
Diagnostic Test Reviewed checkboxThe Diagnostic Test Reviewed checkbox adds an indication into the Assessment text box that the Diagnostic Test was reviewed.
10
Assessment panel
The Assessment panel is used to provide assessment notes to the diagnosis for the patient encounter.