On the Assessment / Plan Details template, the provider selects an assessment and then enters any pertinent comments, differential diagnoses, plan details, provider details, or today's orders with the option to use My Phrases or Common Phrases (practice-wide phrases), and Follow-Up. Entering information in A/P Details tab is optional.
The A/P Details tab includes the following sections:
- Today's Assessment grid: You can add, edit, sort, and remove rows. The columns include the diagnosis priority number (#), Description, Code, and Status.
- Impression/Comments memo field: You can enter text, record audio, and access My Phrases. The data entered here also appears in the Assessment / Plan panel. You can select Comments link to open the A/P Details tab directly from Assessment / Plan panel to update the comments. The first 215 characters entered as impression details can be reviewed in the Problems module, Billing ICD List tab and Note field.
- Differential Diagnosis field: You can enter text or use the My Phrases functionality to insert phrases in the field.
- Patient Plan field: You can enter text, record audio, or select phrases using the My Phrases/Common Phrases link; for more information on the Exceptions link, go to NextGen Healthcare Success Community, and download the latest Provider CQM Maintenance System Template forNextGen®Adaptive Content Engine. When you add any phrase in Patient Plan field, the documented phrase appears on the Assessment / Plan panel as a link that you can select to open. You can select Patient Plan link to open the A/P Details tab directly from Assessment / Plan panel to update the patient plan.
- Provider Plan field: You can enter text, record audio, or select phrases using the My Phrases/Common Phrases link. When you add any phrase in Provider Plan field, the documented phrase appears on the Assessment / Plan panel as a link that you can select to open. You can select Provider Plan link to open the A/P Details tab directly from Assessment / Plan panel to update the provider plan.
The Chart Note document prints plan information from both the Patient and Provider Plan fields. A generated Patient Plan document includes only the Patient Plan details.
