Document Assessment and Plan in the OB Postpartum Template

You can document assessment and plan information in the OB Postpartum template.

1. Select the Postpartum tab.
2. Select the Physical Exam panel.
3. Select the Add/Update button in the Assessment/Plan panel.
   The Add or Update Assessment template opens.
4. Enter the applicable information in the Add or Update Assessment template.
   By default the ICD-10 code displays in the Assessment/Plan grid. The system assigns the ICD code to the Assessment field on the template. This code displays by default for the Visit Type of OB Postpartum and does not include Document Pregnancy Outcome which is typically done without the patient being present.
5. Select Save & Close.
6. To enter information in the Consent – Procedures template, select the Consent link.
7. To generate the proc_consent document, select the Consent button.
8. To enter information in the Procedure Scheduling link, select the Procedure Scheduling button.
9. Select the CQM icon to display information for the CQM – Maternity Care – Post-Partum Follow-up and Care Coordination measure.
10. In the Counseling section, select the applicable checkboxes in the Counseling section.
    Note: Any findings that are selected in the Counseling section are provided on the Home Page – Obstetrics template / Summary / Plans section.
    • If Yes is selected in the Gestational diabetes field, an application message displays from the Postpartum Check section of this template to remind the provider to check the glucose. The Gestational diabetes field shares from the Postpartum Check section of this template.
    • If No is selected in the Gestational diabetes field, the application message does not display in the Postpartum Check section of this template.
    1. In the Contraception section, select the current and/or planned birth control options.
    2. To follow the standards for confidential information, select the Include information in the document checkbox, if applicable.
    3. Select the Other field to enter text in the field, if applicable.
    4. Enter applicable text in the Additional plan details text box.