Part 1 - Diagnosis
In this lesson, we will start the manual encounter documentation. By default, the patient chart opens to the Diagnosis & Treatment Plan tab.
Documentation for most Better Day Health encounters begins by diagnosing the patient and entering all ICD-10 codes. There are a number of ways to quickly add them to the chart.
First, ICD-10 codes can be searched for and added to the chart using the search bar.
- Start by typing the code or description of the diagnosis, and the menu will begin to autofill with results.
- Select the code needed, and click Add. Codes added to the chart will appear below the search bar.
By typing in a description of the diagnosis and clicking on the magnifying glass next to the search bar, a new browser tab will open with search engine results for that code.
Codes can also be added by searching the ICD-10 grid. Here, ICD-10 codes are organized in three sections.
The first section displays the patient's current diagnosed problems. These codes have been used in previous appointments and can be quickly recalled here.
The second section is a list of provider favorites. They are categorized in groups and can be added by clicking the diagnosis favorite. Favorites can also be searched for. Begin typing, select, and click Add.
ICD-10 favorites are set up during implementation and can be updated and changed at any time by your clinic administrator.
The last column displays a list of most-recently-used ICD-10 codes. These also can be added to the patient chart by clicking.
It is possible to change the order of these codes. Simply click/hold, drag, and drop.
To remove codes from the chart, click the X on the right hand side.
The next section of the Diagnosis & Treatment Plan tab displays results from Isabel's database.
3. Differential diagnoses can be filtered based on patient symptoms and complaints found in their chart and pre-check in questionnaire. You can browse and select the various descriptions.
4. Click on an option to review additional codes and (4b) add them to the patient chart.
Part 2 – Treatment Plan
This part of the patient chart allows for the documentation of the patient's treatment plan.
- In the first section you can type or dictate an overall assessment using Nuance and a computer-connected microphone,
- Clicking View Previous will allow you to access and review any previous appointments and past summaries. When finished click save.
When finished, X out of page.
The sections below the Overall Assessment & Plan contain all of the orders to be included in this treatment plan. Follow up appointments, orders, procedures, and more can all be added to the plan here.
3. Like in other tabs of the patient chart, we can click New to add a new order to the list and Remove to delete an item.
Once the treatment plan is complete, return to the top of the page and continue to Billing.