Assessment & Plan is the portion of an exam that correlates coded diagnoses and findings with suggested treatment plans, as well as a place to add generalized comments on health concerns and state health outcome goals for the patient. This tutorial will demonstrate how to document and plan as part of a patient exam in Vision(X).
Assessment & Plan Menu
Begin the exam, then select the Assessment & Plan category to open the documentation fields. If this portion of the exam has already been documented by another provider, or will simply not be performed as part of today's exam, select the check boxes as appropriate. If any codes were marked for diagnoses as part of a previous portion of the exam (such as when entered as part of a physical finding when evaluating Ocular Health), they will automatically appear in "Today's Diagnoses." To add an additional diagnosis code, search select from the "Add Diagnoses" field:
Today's Diagnoses
Codes left as diagnoses will appear as billable for today's exam. Any of the codes selected for Today's Diagnoses can be adjusted to "Finding" status as necessary. Click the drop-down arrow next to each diagnosis to view additional documentation fields. Enter information as appropriate, then continue to the next diagnosis:
Near the bottom of this exam section are additional, optional fields for Comments, Health Concerns, and Goals:
When ready, double-scroll the bottom of the page to proceed to the next portion of the exam:
