Assessment

Assessment is available in the following encounter types: Exam, Multi-System, Historical, Immunization, Procedure, Reconciliation, Telephone, and Urgent Care.

• The Assessment Add (Favorites) list is customizable at the user and CLINIC level. Go to Tools > Preferences > CLINIC or [user] > Form Data > Begin Edit and select Assessment from the Tab list
• The selection list items for Severity can be customized by the Clinic Administrator by going to Tools > Preferences > CLINIC > Clinic Wide Form Data > Begin Edit and selecting Assessment from the Tab list
• A checkbox option to require an assessment resolved date when resolving an assessment can be enabled by the Clinic Administrator in Clinic Settings: General
• Text formatting for the Problem List on the encounter Note Display can be set by the Clinic Administrator by going to Tools > Preferences > CLINIC > Clinic Settings: Display

The problem list displays all the patient's active problems and any new assessments added during the visit. The list displays the Problem name, ICD‑10 code, Onset, Chronicity, Severity, and Progress for the patient's active assessments. Columns for ICD‑9 codes and mapped SNOMED CT codes will also display if the patient has these codes in their current assessments.

• To view the assessment details, select the problem. The details display in the area above the problem list
• To access patient education for a problem, click (Infobutton) next to the Problem column or click in the Pt Ed column to launch MedlinePlus Connect website resources

Assess an Active Problem

1. Go to Encounter > Assessment
2. Select the problem
3. Select Assess
   1. Selecting Assess will automatically select Bill
4. Optional: clear the Bill checkbox if the assessment will not be billed for the encounter
5. Optional: click Change to update the Chronicity, Severity, Progress, Anatomical location site, or Note for the problem
   1. The Chronicity, Severity, and Progress can be updated directly from the problem list

1. Go to Encounter > Assessment
2. Click Add (Favorites) or Add (Master List)
3. Select an ICD‑10 code
   1. If using the Favorites list, select a favorites Category, then select the ICD‑10 code
   2. If using the Master List, search for and locate the ICD‑10 code and click OK
4. Populate the Onset Date or leave defaulted to the encounter date
   1. If the onset date is unknown, select Existing Assessment
5. Optional: select a Chronicity, Severity, Progress, or Anatomical location site
6. Optional: Type a Note to document any additional information
7. Click Add or click Add Another and repeat the steps to add more assessments

Assessments added to the encounter are automatically marked as Billed and Assessed.

Assessment Note and Health Concerns are free text fields used to document additional information or concerns as they relate to the assessment(s) of the current visit. The information documented in these fields is encounter-specific and does not carry forward to subsequent visits.

The No active problems checkbox is for use with patients who have no active problems and can be used in conjunction with ICD‑10 codes for the reporting of factors influencing health status and contact with health services (Z codes).

The checkbox will display as disabled for patients with active problems that are not Z codes.

1. Click View Historic
2. Select an Assessment Status: All, Active, or Inactive/Resolved
3. Select an Assessment from the list
4. Select a Time Frame for the history

1. Select a Problem
2. Click Map SNO
3. Select a SNOMED CT for mapping
4. Click OK