On the Assessment Plan Details template, select the A/P Details tab.
To add or change a diagnosis in the Today’s Assessments grid, select Add or Edit to open the Add or Update Assessment template.
To change the current working assessment, in the Today's Assessments grid, select the diagnosis being addressed for this encounter.
The selected diagnosis appears in the Selected Dx field. It becomes the new working assessment that carries forward to the other templates that share the assessment.
Enter details manually or use My Phrases or Common Phrases for the impression, differential diagnosis, and patient and provider plans in the respective sections.
To enter follow-up appointment and disposition information, select Follow Up.
To document counseling educational details and factors, select the Counseling Details link.
To enter post-operative details, select the Postoperative Quality Reporting link.
For more information on the associated quality measure, select Q.
Save the encounter details.
Document Follow-up Details You can enter follow-up appointment and disposition details on the Follow-up/Disposition template.
Document Postoperative Concerns You can document the type and date of postoperative complication(s) specifically for Quality Reporting reasons in A/P Details in the Assessment / Plan panel on SOAP.
Save the Documented Assessment Details After you have completed documenting the patient's plan and associated details, there are different options for proceeding with the encounter.
