Description

Allows users to customize the narrative produced by the configuration ,of the Assessment and Plan sections.


Access


Through Main Menu 

  • Click on the Clinical button, in main menu. 
  • Select patient from any section of the Clinical Records screen. 
  • Once patient is selected, click on the Settings button, located at the top of screen. 
  • Select the Assessment & Plan Settings option.


Sections


Botones

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


  • Display Settings: Allows to select the style, user would like to display the assessment and plan. 
    • Use Paragraph Style: By selecting this option, the assessment and plan, will be displayed, as a paragraph. 


    • Use Sorted Style: By selecting this option, the assessment and plan, will be displayed as sorted list. 


    • None: By selecting this option the assessment and plan area wont make any changes. 


  • Assessment Templates: This section includes all of selected Keywords from the Available Keywords list, on the right panel. The order in which they are listed on this window, is also the order in which they will appear, on the Assessment section.
  • Plan Templates: This section includes all of selected Keywords from the Available Keywords list, on the right panel. The order in which they are listed on this section, is also the order in which they will appear on the Plan section.
  • Available Keywords: Displays all of the available keywords, to create clinical narratives in both the Assessment and Plan sections. The available Keywords are:
  • Active Allergies: When selecting, displays the patient's active allergies.
  • Active Diagnosis: When selected, displays the patient's active diagnostics.
  • Active Medications: When selecting, displays the patient's active medications.
  • Allergies Diagnoses: When selected, displays the diagnosed allergies.
  • Allergies Inactivated: When selected, displays the patient's inactive allergies.
  • Cancelled Medications: Upon selecting, displays the patient's cancelled medications.
  • Chief Complaint: When selecting, displays the patient's main complaint.
  • Counseling For Nutritional And Physical Activity: When selecting, displays whether the checkbox on the vital signs screen of the patient's nutrition and physical activity orientation, was selected.
  • Developmental Milestones: When selecting, displays the pediatric patient development. 
  • Discontinued Medications: When selected, displays the patient's discontinued medications. 
  • Education Handed Out: When selecting, displays the educations given to the patient.
  • Follow Up: When selected, displays the patient's follow-up visit instructions.
  • Future Orders: When selecting, displays the patient's future orders.
  • Goals: When selecting, displays the patient's stated goals.
  • High Risk Of Falling: When selected, displays whether the patient may be at high risk for falling.
  • Immunizations: When selected, displays the patient's administered vaccines. 
  • Inactivated Diagnosis: When selected, displays the patient's inactive diagnosis. 
  • Instructions: When selecting, displays the patient's instructions. 
  • Life Expectancy 6 Months: When selected, the option selected in the clinical evaluation will be displayed.
  • Medications Reconciliation Performed: When selected, displays patient's medication reconciliation performed. 
  • No Known Allergies: When selected, displays if it's chosen that the patient does not have any type of allergy. 
  • Optimal Instrument: When selected, the instrument measuring difficulty through 22 options, which a patient needs to carry out various functional activities, will be displayed where the difficulty was transferred.
  • Orders Given: When selecting, the orders given on the day of the meeting will be displayed.
  • Orders Given with Templates: When selecting, the orders given on the day of the meeting, which contain some "template", will be displayed.
  • Patient Summary: When selected, the patient's clinical summary will be displayed.
  • Phone Calls: When selected, the calls made will be displayed.
  • Prescribed Medications: When selected, the drugs prescribed to the patient will be displayed.
  • Prescribed Medications Without Notes: When selecting, the drugs prescribed to the patient will be displayed without containing no notes.
  • Procedures Performed: When selected, the procedures performed on the patient will be displayed.
  • Questionnaires: When selecting, the questionnaires given to the patient at the meeting will be displayed.
  • Referrals Given: When selecting, the referrals given to the patient will be displayed.
  • Referrals Completed: When selecting, the patient's completed referrals will be displayed.
  • Resolved Diagnosis: When selected, the patient's resolved diagnoses will be displayed.
  • Rule Outs: When selected, the patient's discarded diagnoses will be displayed. 
  • Smoking Status: When selected, the patient's smoking status will be displayed.
  • Todays Anticipatory Guidances: When selected, advance patient me guides will be displayed.
  • Todays Blood Sugar Tests: Upon selection, blood sugar tests from the day of the match will be displayed.
  • Todays Diagnosis: When selecting, the patient's diagnosis of the encounter day, will be displayed.
  • Todays Diagnosis With Notes: When selecting, the patient's diagnoses will be displayed, with notes from the day of the encounter.
  • Todays Discontinued Medications: When selected, the patient's discontinued medications will be deplayed.
  • Todays Menstrual History Entry: When selected, the patient's menstrual history of the encounter day, 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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