Visit Note Documentation Guide- Assessments

Table of Contents

• Documenting Assessments
  • Narrative Assessments
  • Coded Assessments
• Coded Assessments & Problem List
• How to disable diagnosis codes in Assessments

 

Documenting Assessments

Every Visit Note Format in Elation contains an Assessment field except for the Simple Note. There are two ways to document clinical assessments during a patient encounter.

1. You can type out a text narrative in any of the assessments fields in Elation
2. You can use the ICD database to enter coded assessments in any of the H&P and Pre-Op Visit Note formats.

 

Narrative Assessments

Write out a narrative assessment in any of the assessment text fields in any of the visit note formats available. If a drop down appears with diagnosis codes you can bypass the drop down and keep typing if desired. The text box will continue to expand to allow you to type as much text as needed. If you choose to use coded assessments, see below.

 

Coded Assessments

By default, the Coded Visit Note Assessments feature is turned on for providers in the Preferences section of their Elation Settings upon account creation. The following workflow applies to any of the H&P and Pre-Op Visit Note formats only. 

1. Click into the Assessment field
2. The patient's list of active problems from their Problem List will appear immediately below. Click a problem from the list to apply it as an assessment, or start typing to find a different assessment from the ICD database.

3. When you start typing, Elation will return search results from our ICD database. 
4. Select the appropriate diagnosis from the list to apply it as an assessment. It will be added to your visit note along with its corresponding ICD-10 code(s).

• The ICD-10 code associated with the diagnosis selected will also be automatically added to the billing section of your visit note.

5. After you select a diagnosis from the search results, you can also edit its description by changing the text that is pre-filled in the assessment field:

 
 

How to disable diagnosis codes in Assessments

By default, ICD-10 codes for your Assessments will show up in your visit note when you print, fax, or share them.

If you do not want Dx codes to show up alongside the assessments in your visit note, you can turn this off in "Settings" >> "Preferences", under Coded Visit Note Assessments. The toggle will be set to "Yes" by default. Change it to "No" to remove Dx codes from your visit note documentation.

• Important Note: This is a Provider Level User Setting and each provider needs to adjust this setting in their own account if there are multiple providers in the practice.

 


 

Related Articles

• Visit Note Documentation Guide- Visit Note Formats
• Visit Note Templates Guide
• Visit Note Documentation Guide- Procedures
• Visit Note Documentation- Physical Exam (PE) & Review of Systems (ROS) Templates
• Billing Guide- Creating a Super Bill and coding for your visit
• Billing Guide- Billing Report