Description

The system enables users to customize the narrative for the clinical evaluation of the patient within the "Assessment" and "Plan" sections. It can be formatted as a paragraph, a list, or omitted entirely.


Access


Through Main Menu 

  • Select the "Clinical" option from the main menu.
  • Select the patient from any section on the "Clinical Records" screen.
  • After selecting the patient, click the "Settings" button located at the top of the screen.
  • Choose the "Assessment & Plan Settings" in the "Progress Note Custom Configuration" section.


Sections


Botones

  • Save: Allows to store changes in screen. 
  • Previous: Allows to close screen. 


  • Display Settings: Allows you to select the way in which the “Assessment” and “Plan” section will be displayed. 
    • Use Paragraph Style: When this option is selected, the “Assessment” and “Plan” sections are displayed in paragraph form.


    • Use Sorted Style:  By selecting this option, the “Assessment and Plan” section will be displayed in the form of a list. 


    • None: By selecting this option, the “Assessment and Plan” section will be displayed without any information.  


  • Assessment Templates: This section encompasses all the selected keywords from the Available Keywords list on the right panel. The sequence in which they are displayed in this window will correspond to the order they appear in the Assessment section.
  • Plan Templates: This section contains all the selected Keywords from the Available Keywords list, located on the right panel. The sequence in which they are listed here is the same sequence in which they will be displayed in the Plan section.
  • Available Keywords: To create clinical narratives in the Assessment and Plan sections, the following keywords are available:
  • Active Allergies: Selecting this option will display the patient's active allergies.
  • Active Diagnosis: When selected, it shows the patient's current diagnostic information.
  • Active Medications: When selected, displays the patient's current active medications.
  • Allergies Diagnoses: When selected, displays the diagnosed allergies.
  • Allergies Inactivated: When selected, displays the patient's inactive allergies.
  • Cancelled Medications: When selected, displays the patient's cancelled medications.
  • Chief Complaint: When selected, the system displays the patient's primary complaint.
  • Counseling For Nutritional And Physical Activity: The system will display whether the checkbox for the patient's nutrition and physical activity orientation on the vital signs screen has been selected upon choosing.
  • Developmental Milestones: When activated, it exhibits the development of pediatric patients.
  • Discontinued Medications: Selecting this option will display the patient's discontinued medications.
  • Education Handed Out: When selected, it displays the educational information provided to the patient.
  • Follow Up: When chosen, it shows the instructions for the patient's follow-up visit.
  • Future Orders: When selected, displays the patient's upcoming orders.
  • Goals: When activated, it shows the patient's expressed objectives.
  • High Risk Of Falling: When activated, it indicates if the patient is potentially at high risk for falls.
  • Immunizations: When selected, it displays the vaccines administered to the patient.
  • Inactivated Diagnosis: Selecting this option will display the patient's inactive diagnoses.
  • Instructions: When selected, the patient's instructions are displayed.
  • Life Expectancy 6 Months: Upon selection, the chosen option in the clinical evaluation will be displayed.
  • Medications Reconciliation Performed: When selected, it displays the performed medication reconciliation for the patient.
  • No Known Allergies: When selected, it indicates that the patient has no known allergies.
  • Optimal Instrument: Upon selection, the instrument that measures difficulty across 22 functional activities required by a patient will show where the difficulty has been recorded.
  • Orders Given: Upon selection, the orders issued on the day of the meeting will be displayed.
  • Orders Given with Templates: When making a selection, the orders issued on the day of the meeting, which include a "template," will be displayed.
  • Patient Summary: Selecting this option will display the patient's clinical summary.
  • Phone Calls: When selected, the calls made will be displayed.
  • Prescribed Medications: Upon selection, the prescribed medications for the patient will be displayed.
  • Prescribed Medications Without Notes: When selected, the prescribed drugs will be displayed for the patient without any notes.
  • Procedures Performed: Upon selection, the procedures conducted on the patient will be displayed.
  • Questionnaires: When selected, the questionnaires given to the patient at the meeting will be displayed.
  • Referrals Given: Upon selection, the referrals provided to the patient will be displayed.
  • Referrals Completed: Selecting this option will display the patient's completed referrals.
  • Resolved Diagnosis: Selecting this option will display the patient's resolved diagnoses.
  • Rule Outs: Upon selection, the system will display the patient's discarded diagnoses.
  • Smoking Status: Selecting this option will display the patient's smoking status.
  • Todays Anticipatory Guidance: When chosen, advanced patient guides will be displayed.
  • Todays Blood Sugar Tests: Selecting this option will display blood sugar test results from the match day.
  • Todays Diagnosis: Upon selection, the patient's diagnosis from the day of the encounter will be displayed.
  • Todays Diagnosis With Notes: Upon selection, the patient's diagnoses along with the notes from the day of the encounter will be displayed.
  • Todays Discontinued Medications: Upon selection, the patient's discontinued medications will be displayed.
  • Todays Menstrual History Entry: Upon selection, the patient's menstrual history for the day of the encounter will be displayed.
  • Todays Orders Results: When selected, the patient's order results of the encounter day, will be displayed.


Assessment and Plan Areas



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