20 Compulink Best Practices – Plan Tab

The Plan Tab is used to record your patient assessment and plan for each condition that you diagnose during the encounter.

For each entry that you create in this grid, enter in an ICD-10 code (type a partial description in the Description field and then press “F7” to search for the closest match to what you’ve typed. Select the most appropriate diagnosis from the search list (or search using different terms if what was returned for your search is inappropriate), and complete the assessment and plan. A few tips are below:

In many cases, the diagnosis code IS your assessment. However, if you need to add additional information, please do so. Note that simply repeating examination findings is generally not appropriate – the examination findings are in the examination, and repeating them here can lead to mistakes in rewriting the data and inconsistencies in your chart. Instead, provide a high level summary of examination findings. Examples are provided below.

Cataracts: “Visually significant”. “Not visually significant”

Diabetes: “No retinopathy”

Glaucoma Suspect: “FxHx:  None, VF:  NL, IOP: NL, PACH:  thick, OCT: NL, CDs:  large”

Iritis: “Secondary to ocular trauma”

If I want further details about these conditions, information should be available in the various examination tabs. Again, provide a high-level summary of your findings when appropriate, but much of the time it’s not necessary to add additional information in the assessment field – the ICD-10 code and description is the assessment.

You’ll generally provide a bit more information in the Plan field. For each diagnosis, briefly describe what you’ll do for this patient. Examples follow:

Myopia: “Rx printed and provided to the patient. Adaptation discussed.”

Lattice Degeneration: “Patient education to RTC STAT if increase in flashes or floaters, or if sudden decrease in central or side vision”

Presbyopia: generally speaking, you have the potential to have up to three refractive diagnoses per patient – myopia, astigmatism, presbyopia, for example.

If you have multiple refractive diagnoses – say hyperopia, astigmatism, and presbyopia – list your plan in the first one (hyperopia), and refer to it in the second and third diagnosis – i.e., “See A&P for Myopia”. This will save you time and effort. Otherwise, each diagnosis should have its own assessment and plan as appropriate.

Return to Clinic: Make sure to always indicate a return to clinic date for your patient, either for a follow-up or a full examination. Briefly list the reason for the follow up in the Reason field, and indicate the doctor who is to see the patient, in the ID field. This is especially important for follow-ups. Click on the appropriate time frame on the left side of the screen, or type in a specific date in the Target field if appropriate.

When checking your patient out and scheduling a follow-up appointment for an acute issue, make sure to tell the staff person to place a note in the schedule indicating that “Perotti/Smith” (the doctor and the intern name) will be seeing the patient at their follow-up appointment.