Analysis and Plan

To add information to the patient's Analysis and Plan, follow the steps below and do not forget to complete the required fields (*).

 

• Complete the Analysis and Plan information. Fields with (*) are required fields and must be completed before saving the record. Fields marked with (-) are autocompleted.
  • • Diagnostic: Enter Patient’s Diagnostic.
    • Post-procedure information for patients: Enter Post Procedure information.
  • Diagnosed Problem: To add a Patient's Diagnosed Problem, click " + New Diagnosed Problem".

• • • Complete the Patient's Diagnosed Problem. Fields with (*) are required fields and must be completed before save the record. Fields marked with (-) are autocompleted.
      • (*) Health Problem: Select the Health Problem from the lookup list (click  or press Enter).
      • (*) Level: Select Low or High.
      • (*) Probability: write the probability number between 0 and 100.
      • Click “Save and Close”.
• For each Diagnosis problem you can create a procedure. Open the Diagnosed Problem created, click Name.

 

• • • Procedures: To add a Patient's Diagnosed Problem Procedure, click " + New Diagnosed Problem Procedure".

• • • • Complete the Diagnosed Problem Procedure information. Fields with (*) are required fields and must be completed before saving the record.
        • Existing Procedure: You can select a previous Procedure created in this Appointment, just select the Procedure from the lookup list (click  or press Enter).
        • (*) Medical Procedure: Select the Medical Procedure from the lookup list (click  or press Enter) You can search by name or by code.
        • (-) Code: This field will be auto created.
        • (-) Standard: This field will be auto created.
        • Performed in the same appointment: Select Yes or No if the procedure was implemented in the same Appointment.
        • Internal: Select Yes or No. If the Procedure was implemented in the same appointment this field will be autocompleted.
        • Place of Service: Select the Place of Service from the lookup list (click  or press Enter). This field will be required if “Internal” is Yes or if “Performed in the same Appointment” is Yes.
        • From: Select the date.
        • To: Select the date.
        • Fee: Enter the Procedure Fee. This value will be autocompleted if the selected procedure has a value configured in the “Procedures Price List.”
        • Discount: Enter the Procedure Discount.

If the Diagnostic Procedure was configured as Internal o Performed in the same appointment, a new record of the type of Internal Procedure will be created and related with the Patient Information.


 

• Assessment and Plan of Treatment: To add a Patient's Assessment and Plan of Treatment, click “+ New Assessment and Plan of Treatment"

• Complete the Patient's Assessment and Plan of Treatment. Fields with (*) are required fields and must be completed before save the record. Fields marked with (-) are autocompleted.
  • (*) Patient: This field will be autocompleted.
  • (*) Intent: Select ​​​​​​​​Intent from: Proposal, Plan, Order or Option.
  • Category Code: Select ​​​​​​​​​​​​​​​Category Code from: Assess-plan.
  • Narrative Summary: Enter ​​​​​​​Narrative Summary.
  • Assessment and Plan of Treatment Status: Select ​​​​​​​​​​​​​​​Intent from: Draft, Active, On-Hold, Revoked, Completed, Entered-in-error or Unknown.
  • Click “Save and Close”.

If you want to clone a previous Assessment and Plan of Treatment, open the record, and click “Edit”.

Then click .

The record will be cloned.

 

• Health Concerns: To add a Patient's Health Concern, click “+ New Health Concern".

• Complete the Patient's Health Concern. Fields with (*) are required fields and must be completed before save the record. Fields marked with (-) are autocompleted.
  • (*) Patient: This field will be autocompleted.
  • (*) Patient Health Concern: Select Patient Health Concern from the look up list (click  or press Enter).
  • Identify By: Select ​​​​​​​​​​​​​​​Identify by from: Patient, Family Member or Provider.
  • Health Concern Observation: Enter ​​​​​​​Health Concern Observation
  • Click “Save and Close”.

 

• Patient Goal: To add a Patient's Goals, click + New Patient Goal"

• Complete the Patient's Goals. Fields with (*) are required fields and must be completed before save the record. Fields marked with (-) are autocompleted.
  • (*) Start Date: Enter Patient's Goal Start Date
  • (*) Life Cycle Status: Select Life Cycle Status from: Proposed, Planned, Accepted, On-hold, Completed, Cancelled, Entered-in-error or rejected.
  • Achievement Status: Select ​Achievement Status from: In-Progress, Improving, Worsening, No-change, Achieved, Sustaining, Not-achieved, No-progress or Not-attainable.
  • Category: Select ​Category from: Dietary, Safety, Behavioral, Nursing or Physiotherapy
  • Goal Priority: Select ​Category from: High-priority, Medium-priority, or Low-priority.
  • (*) Description: Enter Patient's Goal Description
  • Expressed By: Select Expressed By from the look up list (click  or press Enter). Then Save the record.
  • Click “Save and Close”.

Open the Patient Goal created in the previous step.

Click  .

• Patient Goal Target: To add a Patient Goal Target, click “+ New Patient Goal Target".

• Complete the Patient Goal Target. Fields with (*) are required fields and must be completed before save the record. Fields marked with  (-) are autocompleted.
  •  (*) Measure: Select Measure from the look up list (click  or press Enter). Then Save the record.
  • Due Date: Enter Patient Goal Target Due Date
  • Enter the Patient Goal Target Detail in one of these fields:

• Detail Boolean.
• Detail Quantity - Detail Quantity Unit.
• Detail Range Low - Detail Range High.
• Detail Ratio.
• Detail String.
• (-) Detail: This field will be autocompleted with the Detail entered previously.
• Click “Save and Close”.​​​​​​​​​​​​​

• Care Plan: To add a Patient's Care Plan, click “+ New Care Plan".

• Complete the Patient's Care Plan. Fields with (*) are required fields and must be completed before save the record. Fields marked with (-) are autocompleted.
  • (*) Name: Enter Patient's Care Plan Name
  • (-) Identifier: This field will be autocompleted after the record is saved.
  • Start Date: Enter Care Plan Start Date
  • End Date: Enter Care Plan End Date
  • Intent: Select ​​​​​​​​​​​​​​​from these values: Proposal, Plan, Order, Option.
  • Context Type: Select from these values: Episode of Care, Encounter
  • Description: Enter Care Plan description
  • Patient: This field will be autocompleted
  • Care Plan Status: Select from these values: Pending, Active, Suspended, Completed, Entered in Error, Canceled, Unknown
  • Click “Save and Close”.

 

• Open the Care Plan created in the previous step.

• • Care Plan Activities: To add a Care Plan Activity, click “+ New Care Plan Activity".

• Complete the Care Plan Activity. Fields with (*) are required fields and must be completed before save the record. Fields marked with (-) are autocompleted.
  • (*) ​​​​​​​Name: Insert Care Plan Activity Name
  • (-) Activity Id: This field will be autocompleted after the record is saved.
  • (*) ​​​​​​​Activity Definition: Select ​​​​​​​​​​​​​​​from these values: Plan Definition, Activity Definition, Questionnaire.
  • Activity Description: Enter Care Plan Activity description
  • Activity Start Date: Enter Care Plan Start Date
  • Activity End Date: Enter Care Plan End Date
  • (-) Patient: This field will be autocompleted
  • Practitioner: Select Practitioner from the look up list (click  or press Enter). Then Save the record.
  • Activity Status: Select from these values: Not Started, Scheduled, In Progress, On Hold, Completed, Canceled, Unknown
  • Click “Save and Close”.

 

• • Care Plan Goal: To add a Care Plan Goal, click “+ New Care Plan Goal".

• Complete the Care Plan Goal. Fields with (*) are required fields and must be completed before save the record. Fields marked with (-) are autocompleted.
  • (*) ​​​​​​​Name: Insert Care Plan Goal Name
  • Description: Enter Care Plan Goal description
  • Due Date: Enter Care Plan Due Date
  • Care Plan Goal Status: Select from these values: Preparation, In Progress, Not Done, On-Hold, Stopped, Completed, Entered-In-Error, Unknown
  • (-) Patient: This field will be autocompleted
  • Click “Save and Close”.
• Click “Save and Close”.