We are currently updating the OP Help Center content for the release of OP 14.19 or OP 19. OP 19 is a member of the certified OP 14 family of products (official version is 14.19.1), which you may see in your software (such as in Help > About) and in the Help Center tabs labeled 14.19. You may also notice that the version number in content and videos may not match the version of your software, and some procedural content may not match the workflow in your software. We appreciate your patience and understanding as we make these enhancements.

Patient Encounter: Assess/Plan

Version 14.19

About Patient Encounter: Assessment

Path: Clinical tab > Patient Chart button > Encounter > New or Open Note button > Assessment
Path: Practice Management tab > Patient Chart button > Encounter > New or Open Note button > Assessment
Path: 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.
Version 14.10

About Patient Encounter: Assess/Plan Tab

Path: Smart Toolbar > Chart button > Encounters tab > Open Note > Assess/Plan tab
Path: Smart Toolbar > Schedule Button > Encounters tab >  Edit button > Assess/Plan tab

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 Assess/Plan tab 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: Assess/Plan Tab Map

Number
SectionDescription
1
Encounter Note Editor tabs

The Patient Encounter Note Editor contains the following tabs:

2
Care Plans tabThe Care Plans tab lists, prints, and manages care plans for a patient’s health maintenance schedule.
3
Visit DateThe Visit date field indicates the date that the patient encounter occurred.
4
Prior Notes tabThe Prior Notes tab lists the previous encounter notes and messages.
5
Templates tab

The Templates tab lists the templates that are created, edited, and reviewed in the Encounter Templates Editor. Templates are pre-written scenarios you can use in an encounter to document common pediatric diagnoses. Templates include detailed descriptions for the usual pertinent positive and negative findings of a wide variety of illnesses, with a standard assessment, plan and ICD-10 coding. Included with your installation of Office Practicum are Pediatric specific templates.

6
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.
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.  
8
Function buttonsThe Function buttons delete an entire encounter note, edit an encounter note, or save an encounter note.
9
Flag as Incomplete checkboxThe Flag as Incomplete checkbox will mark an encounter as unfinished.
10
Phrase Construction buttonThe Phrase Construction button opens the Phrase Construction window.  Phrase Construction assists with the creation of notes and other text-based descriptions.
11
Diagnostic Test Reviewed checkboxThe Diagnostic Test Reviewed checkbox adds an indication into the Assessment text box that the Diagnostic Test was reviewed.
12
Assessment panelThe Assessment panel is used to provide assessment notes to the diagnosis for the patient encounter.
13
Patient Education Given checkboxThe patient education given checkbox provides 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.  
14
Plan/Patient Instruction panelThe Plan and Patient Instruction panel text box provide notes to the plan (solution) and patient instructions.  The notes in this text box will appear based upon the Plan/Patient Instruction radio button selections.
15
Plan/Patient Instruction radio buttonsThe Plan and Patient Instruction radio buttons are used to toggle between the notes inside the Plan or Patient Instruction text box.  Selecting Plan will display the Plan notes in the text box.  Selecting Patient Instruction will display the note inside the patient instructions text box.
16
Copy buttonThe Copy button copies the text in the plan notes and pastes the notes in the patient instructions text box.
17
Order WorksheetThe Order Worksheet assigns tasks to departments within the practice. Tasks can be associated to an encounter or well-visit template and automatically populate the Order Worksheet.  Tasks can also be assigned through each of the tabs located on the Order Worksheet.
  • : The Order Worksheet Summary tab displays the tasks/orders with their corresponding special instructions, diagnosis, CPT codes, date, and status.
  •  : The Medication Entry tab allows you to create, add, refill, print, send and review prescriptions from this location.
  • : The Diagnostic Test and Lab Entry tab is where you can add a diagnostic test, create a diagnostic test order, modify an order, and perform a diagnostic/test requisition from this location.
  •  : The Immunization tab allows you to create and modify tasks for immunizations in this location.  Clicking the needle icon accesses the patient’s immunization chart.   Recommended vaccines are indicated at the bottom of the order worksheet.
  • : The Patient Education tab allows you to create, modify, and view resource/handout orders from this location.
  •  : The Survey tab allows you to create, modify, and administer survey orders from this location.  Clicking the Do Now button opens the Survey window.
  •  : The Follow Up Task tab allows you to create and modify follow up orders, and select to schedule a followup from this location.  Clicking the Do Now button opens the Schedule and Practice Workflow window
  •  : The Other Task tab is where you can add a referral letter, create tasks for miscellaneous activity, modify a task, and perform tasks from this location.  Clicking the Add Referral Letter button opens the Referral/Care Transaction Details window.
18
Order Worksheet Task buttonsThe Order Worksheet Task buttons are used to:
  •  : Delete a task, remove highlighted order.
  • : Save and assign tasks.  Creates a checklist of tasks for the current tab.
19
Do Now buttonThe Do Now button performs the selected task.