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Medical Practice follows the SOAP principle of Analysis. Field Description : Subjective: Chest Pain - Chief Complaint - HPI Objective: Examine - ROS - Physical Exam Assessment: Look at last Lab / Rad results, and draw conclusions Plan: Investigations, Prescription, Procedures Complaints: The chief and other complaints entered in HPI are shown here for reference. Health Status: The system has a provision to select the Health Status of the Patient in the current encounter. When an encounter is created the default status is copied from the previous encounter. This feature is implemented if Assessment > assessment.healthstatus.use is set to Y. Note that Health Status is also one of the filter conditions used to select the required Face sheet layout for this encounter. Follow up: Select the number of days after which the Patient is to be called after, for a follow up visit. If the Follow up is modified then an urgent message is sent to all users who are working as Front Desk. Follow up Reason: Enter the follow up reason or click on the Search icon to select it from the Phrase Search popup. copy button: Many Doctors want to copy Assessment details from a previous encounter. Click this button to invoke list of encounters for the patient. On selecting an encounter, all its associated ICD/ CPT/ HCPC will be copied (if they are not already present). The following properties should be SET as Y for ICD, CPT, and HCPC codes: Assessment > assessment.icd.copy Assessment > assessment.cpt.copy Assessment > assessment.hcpc.copy Note: The Copy button is available only if the User has more than one encounter. NQF: The NQF button invokes the 'NQF Compliance Status' popup that displays the compliance status of encounter's Attending Provider. The compliance status applies to the NQF measures, including its Exclusion, Denominator and Numerator. It refers to the current encounter and the overall % of the measurement period.ICD TAB Every complaint selected in HPI has a corresponding template and ICD code defined in Settings > Configuration > Complaints Master. The ICD codes associated with selected complaints will appear. Also, all the ICDs from the past medical history will be shown. Del: A checkbox option provided with each ICDs when selected and saved deletes the component ICDs from the list. User can select a common delete checkbox to delete all the ICDs available with a single click. Description : Select additional applicable diagnostic ICD codes by clicking on this button. ICD Search popup: ICD search can be done either from Provider's preferred ICD list or from the ALL the ICDs present in the system. Preferred tab: By default the Preferred ICDs option is selected, select the option to search for ICD code from Provider's preferred list of ICD codes. Either directly select the codes (if available) from the list displayed or enter specific code or code description in the Search field and click on button, GO. All tab: Select All tab and either enter a code or code description in the Search field and click on button, GO. Custom tab: It facilitate Users to add customized codes. A separate search is provided to list out all the existing custom created codes. Selected: The field displays the codes that are selected by the User from the search result displayed. Clear: On click, clears the selection from the ‘Selected' field. Search By: ICD/Description: Enter the either code or code description in the field. SNOMED US: Select this option and enter a US SNOMED code directly in the 'Search' field to search for results. SNOMED Int'l: Select this option and enter a International SNOMED code directly in the 'Search' field to search for results. Navigational arrows:
Following is the column details of the list: Description : The column displays the code description. ICD9 : The column displays the ICD 9 code number. SNOMED Int'l : The column displays the International SNOMED code number. ICD 10 : The column displays the ICD 10 code number. Type : The column displays the type of the ICD code. Add to Preferred : Click on the button to add the selected code to Provider’s preferred list. Note: This button is available only when All ICDs option is selected. The add icon is displayed along side the code only if the logged in Provider is the Attending Doc of the open Encounter i.e. a Provider can add to his/her preferred list if he/she is the attending doc of the open encounter. The ICDs are then added to the provider's preferred list. Remove from Preferred : Click on the button to delete the selected code from Provider’s preferred list. The remove icon is displayed only if the logged in provider is the Attending Doc of the open Encounter i.e. A Provider can remove from his/her preferred list if he/she is the attending doc of the open encounter. The ICDs are then removed to the provider's preferred list.Ok : Click ok button to close ICD popup and add the selected code(s) as row(s) on the Assign ICD popup. User can select required ICDs. button: Click the button to select from the list of ICDs (ICD9 and ICD10) assigned in Past Medical History. There are many existing Medical Problems, which are also taken into consideration by the Doctor (like diabetes, hyper tension) although the complaint might not directly pertain to them. This is an easy way to get a list of all History of the problems for the Patient and select relevant ones. button: Click on the button to select from the list of ICDs (ICD9 and ICD10) assigned to multiple complaints. Multiple ICDs can be assigned to a single complaint in the ‘Complaint’ master. button: Click the button to invokes a PopUp for the user if he wishes to rearrange the order in which ICDs are billed. Some times a provider may select an ICD which is most relevant after the ones that are lesser relevant. In such case the user can, with the help of Move Up / Move Dn Buttons, rearrange the sequence of ICDs. ICD9 : This displays the ICD9 code for the selected or added ICDs. ICD10 : CThis displays the ICD10 code for the selected or added ICDs. Note: User is appropriately prompted with an alert whenever an ICD code starting with ‘E' (Procedural ICD) is attempted to be marked as the primary ICD. Note: ICD code starting with ‘E' can not be used as the primary ICD. Note: The email sent has a defined format that can be configured from Email Configurator screen (Settings → Configuration → Email → Patient Education Material option). For patients who have been given the education materials, the record is seen on the Patient Education screen (GoTo Patient → Encounter → TOC → Education) on the current tab – with all options disabled. Assessment & Plan: The two notes fields on the right, allow user to enter the Assessment and Plan notes for the selected ICD row. The notes can be entered as a free text.Click on the Phrases icon to select from the list of pre-defined Phrases and add them to the notes. The different types of Phrases used in PrognoCIS are displayed as per category. User can perform search based on the Category, phrase title and/or textual search or search based on keywords. User can insert a single or multiple phrases by selecting single or multiple checkboxes. Five Buttons for Rx, Lab, Rad, Consult and Procedure are provided to enable users to select corresponding Drugs/Tests for the ICD Code row selected. Click on the button to invoke the appropriate search. The selected Tests will be added to Order Sheet (or Prescription) with corresponding ICD Code. The Button tool tip displays all Lab / Rad / Consult /Rx / Procedure the drug name (with strength). And on click on Procedure the procedures selected are also displayed as part of Plan. Multiple ICDs can be added to the Rx through the Assessment screen and on save of Prescription these ICDs are added to the respective Assessment Plan. Note: When a Nurse goes to Order Sheet, the ICDs against which the tests were selected, will already be selected in the List Box (Unless the ICD was deleted from the Assessment). Add to Preferred: This check box will be displayed depending on the settings in property, Assessment > assessment.icd.add2pref. If this is displayed and is checked, this current ICD code is added to the Doctor's preferred list of ICD codes. If it is not displayed, all selected ICD codes are added to the Doctor's preferred list of ICD codes.CPT/HCPC Tab The Billing depends on the Procedures in the encounter. For each Selected CPT/HCPC row displayed here, there is a Search button. Click on this to select any CPT/HCPC Modifier Code. Del: A checkbox option provided with each CPT/HCPC when selected and saved deletes the component CPT/HCPC from the list. User can select a common delete checkbox to delete all the CPT/HCPC available with a single click. Type: Displays the type of code i.e. either CPT or HCPC or SNOMED Descsription : Select required CPT/HCPC Codes by clicking on this button (which, like ICD search list will also display a Doctor Preferred and All CPT/HCPC code list). Click on a selected CPT/HCPC row to make it current. CPT/HCPC Search popup: The search is functional for Doctor Preferred and All CPT/HCPC codes. Preferred CPT/HCPC tab: By default this option is selected and a doctor preferred list of CPT and/or HCPC is displayed. Either directly select the codes (if available) from the list displayed or enter specific code or code description in the Search field and click on button, GO. All CPT/HCPC tab: Select this option and either enter a code or code description in the Search field and click on button, GO. Custom tab: It facilitate Users to add customized codes. A separate search is provided to list out all the existing custom created codes. Selected: The field displays the codes that are selected by the User from the search result displayed. Clear: On click, clears the selection from the ‘Selected' field. Search By: Code/Description: Enter the either code or code description in the field. SNOMED US: Select this option and enter a US SNOMED code directly in the 'Search' field to search for results SNOMED Int'l: Select this option and enter a International SNOMED code directly in the 'Search' field to search for results Navigational arrows:
Following is the column details of the list: Code Type : The column displays the type of the code i.e. either CPT or HCPC or SNOMED. Description (SNOMED) : The column displays the code description. Code : The column displays the CPT or HCPC or the SNOMED code. SNOMED Int'l : The column displays the SNOMED code number Type : It displays the type of the CPT/HCPC code Remove from Preferred : Click on the button to delete the selected code from Provider’s preferred list. The remove icon is displayed only if the logged in provider is the Attending Doc of the open Encounter i.e. A Provider can remove from his/her preferred list if he/she is the attending doc of the open encounter. The CPT/HCPCs are then removed to the provider's preferred list. Ok : Click ok button to close CPT/HCPC popup and add the selected code(s) as row(s) on the Assign CPT/HCPC popup. Code: The column displays the selected code (either CPT or HCPC). Modifier: To facilitate charging for extra services rendered, the Doctor may select CPT/HCPC Modifier code for the selected CPT/HCPC row, using the Search button. Modifiers that are associated to CPT/HCPC automatically get added to Assessment screen. Note: If there are modifiers associated to CPT/HCPC master and on specialty template, then the preference will be given to specialty template and accordingly codes get added to the assessment screen. ICD : The button when clicked lists all ICDs selected with ICD9 and ICD10 codes on the ICD tab. User may assign one or more ICDs to the CPT/HCPC code on the selected row.Source: The CPT/HCPC' s can be auto-populated from various sources.
Surgery: Check box to indicate if this procedure is performed as Surgery. Note: The Surgery checkbox is available for User to assign it to a procedure even before a save. Add to Preferred: The settings in Assessment property, assessment.cpt.add2pref. automatically adds Selected CPT Code to the Doctors preferred List of CPT codes.Note: User accessing a patient's Claim record from the billing module is promptly informed of changes being done to the assessment code(s) in EMR affecting the same Claim. A prompt is displayed alerting the User of change being done in EMR. Notes TabA provision for the Doctor to enter the Assessment and Plan for each selected ICD was explained on the ICD tab. However many Doctors may prefer to enter one comprehensive Assessment Note and Plan Note. This can be done here. There is also an option for comprehensive Planned Procedure Note. For each of these notes, a select button is provided to choose one or more phrases from a standard list. Click on the Phrases icon to select from the list of pre defined Phrases and add them to the notes. The different types of Phrases used in PrognoCIS are displayed as per category. User can search phrase on any keyword and also view the category associated to phrase. User can insert a single or multiple phrases by selecting single or multiple checkboxes. A icon has been provided to view / edit notes in a larger area in a new pop up. Note... : The button is displayed if the property, assessment.encnotes.template when set with a progress notes template name. On click, the Note… button invokes a popup that displays Encounter Progress Notes for the User's reference. Form... : The button is displayed if the property, assessment.doctorform.code when set with a Doctor Form code . On click, the Form… button invokes a popup that displays the Doctor Form whose code is set in the property for the User's reference. The Doctor Form displayed is editable. |