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.

Alignment

Make sure that you first diagnosis aligns with your chief complaint.  A chief complaint of near blur should likely have a first diagnosis of presbyopia – and not chalazion – for instance.

Your primary diagnosis should also align with the patient’s insurance.  A patient with medical insurance should not have a primary diagnosis of myopia.  A patient with vision insurance should not have a primary diagnosis of glaucoma.

Assessment and PlanView Chapter

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 returned list or search using different terms), 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 thus 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:  consider creating a table of all pertinent information for glaucoma suspects.  The table would include the following:

FxHx:  None

VF:  NL OD, OS

IOP: NL OD, OS

PACH:  thick OD, OS

OCT: NL OD, OS

CDs:  large OD, OS

Gonio:  NONE

Looking over the table, one would likely conclude that the patient didn’t have glaucoma, as most of the data seems to point away from that conclusion.  Additionally, it would also show that gonioscopy should be performed at some point.

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.

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 – group them together and 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

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.

If a patient needs a follow-up appointment for an acute issue, always schedule an appointment before the patient leaves.  If they need to change it later, they can call.  Putting it in the schedule at check-out indicates that the appointment was strongly recommended, and puts the onus of responsibility on the patient if they don’t show and things take a turn for the worse.

Finally, ask 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.