ICD10 | Assessment and Plan Documentation Options

Purpose

This article will describe the differences in the available ICD10 dot phrases within DocNow so that clinicians can fit the phrase that works best when creating assessments and plans within DocNow. 

Audience

DocNow administrators and end users. 

Overview

The assessment and plan section can populate the selected ICD codes in various ways, below will show you the different formats and how they can be utilized. All options can be built into the template or manually populated. Each option will populate the ICD codes that you have selected on the right chart panel within the diagnosis section. When discussing these phrases you may hear the team refer to them as dynamic, meaning that they will update as edits are made to the right chart panel diagnosis section.

*** will show up in some phrases next to the ICDs, they are place holders marking mandatory fields. To toggle between them you can utilize “Shift” + “down” or “Shift” + “up”

Table of Contents

• Admin Set Up
• Provider Workflow
  • Option 1 - .icd10@dn
  • Option 2 - .icd10list@dn
  • Option 3 - .icdlist@dn
  • Option 4 - .icd10ap@dn
  • Option 5 - .icd10note@dn
  • Option 6 - Non Dot Phrase - Search with #

Admin Set Up

The phrases shown below are most often used in a note template which is set up through the admin portal. They are found frequently in Assessment and Plan sections of the template. 

 
Provider Workflow

Option 1 - .icd10@dn

• This phrase is more utilized to show a list of the ICDs for the patient rather than a list to document your plan next to.
• You can reorganize the ICDs using the right chart panel.
• If spaces are entered between the codes using “enter”, it will separate the phrase coding, the highlights will disappear and the phrase will no longer be dynamic.

Option 2 - .icd10list@dn

• This phrase populates with a *** to stop from signing the note without documentation being added for each assessment. 
• You can reorganize the ICDs using the right chart panel.
• If spaces are entered between the codes using “enter”, it will separate the phrase coding, the highlights will disappear the phrase will no longer be dynamic.

Option 3 -  .icdlist@dn

• This phrase is the same as option 2 with the ICD code showing in front of the description.
• You can reorganize the ICDs using the right chart panel.
• If spaces are entered between the codes using “enter”, it will separate the phrase coding, the highlights will disappear the phrase will no longer be dynamic.

Option 4 - .icd10ap@dn

• This phrase displays each ICD with its own A/P fields for separate documentation. 
• You can reorganize the ICDs using the right chart panel.
• There are preconfigured spaces between ICD lines, additional line spacing using “enter” will separate the phrase coding, the highlights will disappear and the code will no longer be dynamic.
• You can enter text under the assessment field and the plan field and it will follow the reorder of the codes.
• Once you save the note and use the .prevnote phrase on a follow-up, it will bring the indicated data from the previous visit. 
• On the subsequent you can also select new ICDs and it will follow the formatting of the initial, allowing a clean continuation of notes with a uniform format.

Option 5 - .icd10note@dn

• This phrase displays each ICD with its own “note” field.
• You can reorganize the ICDs using the right chart panel.
• There are preconfigured spaces between ICD lines, additional line spacing using “enter” will separate the phrase coding, the highlights will disappear and the code will no longer be dynamic.
• You can enter text under the note and it will follow the reorder of the codes.
• Once you save the note and use the .prevnote phrase on a follow-up, it will bring the indicated data from the previous visit. 
• On the subsequent you can also select new ICDs and it will follow the formatting of the initial, allowing a clean continuation of notes with a uniform format.

Option 6 - Non Dot Phrase/ Non Dynamic - Search with #

• When you type # (feature will have to be enabled), the entire list of ICDs will populate as a dropdown for selection.
• You can search by code or description.
• As you select codes, they will populate on the right chart panel under the diagnosis section.
• Cannot be utilized simultaneously with any of the above dynamic phrases.
• Stability varies by browser/device type