- Subjective: 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 compliant 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 the property assessment.healthstatus.use is turned ON. 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.
Order Sheet icon:
This icon remains enabled by default and the tooltip displayed on this icon is Order Sheet.
On clicking this icon, the Order Sheet popup is invoked.
View Encounter Notes icon:
This is displayed only if a Progress Notes template is present in the property assessment.encnotes.template.
On click, this icon invokes a popup that displays Encounter Progress Notes for users' reference.
This icon remains enabled by default and the tooltip displayed on this icon is View Encounter Notes.
Doctor Form icon:
This icon is displayed only if a Doctor Form template is present in the property assessment.doctorform.code.
On click, this icon invokes a popup that displays the Doctor Form for users' reference.
The Doctor Form displayed is editable.
This icon remains enabled by default and the tooltip displayed on this icon is Doctor Form.
Copy From Previous Encounter icon:
This icon allows clinic users to copy Assessment details from a patient's previous encounter to their current encounter.
Click this button to invoke a 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 to ON for ICD, CPT, and HCPC codes:
assessment.icd.copy, assessment.cpt.copy and assessment.hcpc.copy.
This icon is displayed only when the patient has more than one encounter. The tooltip displayed on this icon is Copy From Previous Encounter: ICD, CPT/HCPC, SNOMED CT, Goals, Notes. This icon becomes enabled when a user makes modifications to the Assessment screen. If there is any unsaved data present on the Assessment screen and the user clicks on the Copy icon, an alert popup is displayed with the message: Do you want to copy Assessment details from previous encounter? Unsaved data will be Lost. Do you want to continue? along with Ok and Cancel buttons. If the Ok button is clicked, then the popup closes, any unsaved data on the Assessment screen is discarded, and data is copied from the previous encounter. If the Cancel button is clicked, then the popup closes and user can make further modifications on the screen as required.
eCQM icon:
Earlier, compliance status and eCQM data and progress for a patient’s encounter was displayed on the eCQM Compliance Status popup invoked on clicking this icon.
This icon is now redundant.
Now, compliance status and eCQM measures data and progress details are displayed in the eCQM Reports tab under the Quality Management section on the Population Health Dashboard.
This button remains enabled by default and on click, invokes a message popup alerting the user to check the Population Health Dashboard.
Claims icon:
This icon invokes the Quality Claims Measure popup which is same as of MIPS-Quality-Claims screen invoked from Encounter TOC.
This icon is displayed as enabled only if the patient has Insurance of Medicare type, otherwise it is displayed as disabled.
The tooltip displayed on this icon is Claims.
Lab Matrix icon:
This icon remains enabled by default and the tooltip displayed on this icon is Lab Matrix.
On clicking this icon, the Lab Order Summary Matrix popup is invoked which displays the details of past Lab Results of the patient.
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 from the Diagnosis Codes popup invoked by clicking on this button.
Diagnosis Codes popup: Users can search for ICDs from either the Provider's preferred ICD list or from the ALL the ICDs present in the system from this popup.
Preferred tab: 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 GO button.
General tab: Select General tab and either enter a code or code description in the Search field and click on GO button.
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.
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.
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 this button to invoke a popup for user 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 cases user can rearrange with the help of Move Up/Move Dn buttons and set the sequence of ICDs.
This button gets enabled only when all ICDs are saved (i.e. when save button is grayed out).
ICD9: This displays the ICD9 code for the selected or added ICDs.
ICD10: This displays the ICD10 code for the selected or added ICDs.
Note:
- User is appropriately prompted with an alert whenever an ICD9 enocunter is assiciated with ICD9 code starting with ‘E' (Procedural ICD) which is also a primary ICD.
- If property assessment.icd.noprimary is turned OFF and user added ICD10 codes starting with ‘V, W, X or Y which is a primary ICD for a patient having ICD 10 encounter then an appropriate alert message displays.
- Ap - Assessment & Plan
- En - E & M
- Spl - Specialty
- OS- Order Sheet
- Vac - Vaccination
- Lab - Lab Order
- Rad - Rad Order
- QDC - Quality Data Codes
Note:
ICD code starting with ‘E' can not be used as the primary ICD.
Bill: Typically the Primary ICD code and up to 4 supporting ICD codes are used in billing. Flag ICD codes required for billing purposes. This will facilitate transfer of data from PROGNOCIS to any billing system in use.
If the property assessment.icd.billable is turned ON, then all the ICDs added by default will be marked billable.
MH (Add to Medical History): If this flag is checked, the current ICD code is moved to patient's Past Medical History, so that it appears under the PMH cell on the Facesheet.
Edu: The Patient Education icon
when clicked invokes Patient Education popup; the material displayed is sourced from Medline Plus.
Based on Patient’s preferred language, the Medlineplus Education material is displayed in that respective language.
The User has option to either take print of the material and give patient print copies or send the same as email to patients.
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.
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.
Rx button is provided to enable users to select corresponding Drugs/Lab, Radiology, Consult, and Procedure Tests for the ICD Code row selected. Click on the button to invoke the appropriate search. The selected Tests will be added to Prescription with corresponding ICD Code.
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:
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).
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
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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.
: 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/HCPCs can be auto-populated from various sources.
- Ap - Assessment & Plan
- En - E & M
- Spl - Specialty
- Vac - Vaccination
- Lab - Lab Order
- Rad - Rad Order
- QDC - Quality Data Codes
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.
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.
SNOMED CT Tab
SNOMED CT (Systematized Nomenclature of Medicine - Clinical Terms) is a standardized clinical terminology that is used by physicians and other health care providers for the electronic exchange of clinical health information. SNOMED codes are the default code required in CCDs while exporting or while importing patient health care data. SNOMED is more universal as it includes representation of Diagnosis(ICD), Procedures(CPT/HCPC), Drugs(RxNorm), Labs/Rads(LOINC), etc. SNOMED US are the SNOMED codes adopted in US.
The SNOMED US and International codes searches the SNOMED codes and shows the matching results of that SNOMED code with various ICDs or CPTs and with various descriptions for that code. So in ICD tab on Assessment if an ICD code or diagnosis description could not be found, then the same SNOMED code or diagnosis can be searched in this tab by selecting the SNOMED Int'l radio button.
Del: When selected checkbox option provided with each SNOMED CT code and click on save button that deletes the component SNOMED from the list. User can select a common delete checkbox to delete all the SNOMED code available with a single click.
Descsription
: Select required
SNOMED Codes by clicking on this button. SNOMED Search popup:
Basically, there are 3 tabs on the SNOMED search popup: ICD, CPT/HCPC and SNOMED.
- ICD: This tab shows all SNOMED codes related to Diagnosis irrespective of whether they have ICDs associated or not. Hence you will find some SNOMED codes in this search where there are no ICD codes associated.
- CPT/HCPC: This tab shows all SNOMED codes related to Procedures irrespective of whether they have CPTs associated or not. Hence you will find some SNOMED codes in this search where there are no CPT codes associated.
- SNOMED: This tab shows all other SNOMED codes not related to Diagnoses or Procedures. For example: Implantable Devices related SNOMED codes are found here.
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
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Following is the column details of the list:
Description : The column displays the code description.
SNOMED Int'l : The column displays the International SNOMED code number.
ICD 10 : The column displays the ICD 10 code number.
CPT/HCPC : The column displays CPT/HCPC code.
Ok : Click ok button to close SNOMED search popup and add the selected code(s) as row(s) on the Assessment screen.
SNOMED CT : Displays the International SNOMED code number.Source : Displays the source tab from where the code has been added.
Comments : Enter any required comment.
Goal
In this, care plan or the expectated result for patient is defined. The added goals are displayed on the MU Summary CCD generated on Encounter Close.
Note:
For Meaningful Use 2, the MU Summary CCD Goals are added from Patient > Care Plan.
Descsription
: Select required
Goal (from the SNOMED search popup) by clicking on this button. SNOMED Search popup:
SNOMED search can be done from the tabs: ICD and CPT/HCPC. At a time maximum only 5 codes can be associated from the SNOMED search popup.
- ICD: This tab shows all SNOMED codes related to Diagnosis irrespective of whether they have ICDs associated or not. Hence you will find some SNOMED codes in this search where there are no ICD codes associated.
- CPT/HCPC: This tab shows all SNOMED codes related to Procedures irrespective of whether they have CPTs associated or not. Hence you will find some SNOMED codes in this search where there are no CPT codes associated.
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
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Following is the column details of the list:
ICD9 : The column displays the ICD 9 code number.
Description : The column displays the code description.
SNOMED Int'l : The column displays the International SNOMED code number.
ICD 10 : The column displays the ICD 10 code number.
Ok : Click ok button to close SNOMED search popup and add the selected code(s) as row(s) on the Assessment screen.
SNOMED : Displays the International SNOMED code number.Comments : Enter any required comment.
A 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, Plan note or Procedure note. This can be done from this Notes tab from the Assessment, Plan and Procedures sections. For each of these sections, 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:
Notes entered in the Plan section in this tab are displayed in the patient's Health Summary in the Progress Note section.