Document Information in the Assessment and Plan Panel

You can document information in the Assessment and Plan panel.

1. Select the Prenatal Detail tab
2. Select the Assessment/Plan tab.
3. To add an assessment, select Add/Update.
4. Select any diagnosis in the Billing Diagnosis History section, the Clinical Problems section or the My Favorites section.
   The diagnosis is added to the center section of the template. The Add Common Asssessment link or the Diagnosis Code Lookup link can be used to search for a diagnosis as well.
5. Select the Add/Update button to add this assessment to the Today’s Assessments grid in the template.
6. Select Save & Close.
   Note: Although My Plan and Plan Details can be opened from the template, these would not commonly be used for prenatal patients. Most plans are entered in the OB flowsheet entry and/or the Problem/Detail list. My Plan can be useful for Order Sets.

   In the Assessment/Plan grid, the follow-up appointments are displayed. Any item in the Assessment/Plan grid can be highlighted and deleted using the Remove button.

   The Consent button generates a consent note if the information has previously been entered on the Procedure Scheduling template. The Procedure Scheduling button opens the Procedure Scheduling template, which displays today's assessments. You can enter proposed procedures with details.