Selecting & Applying a Treatment Plan from the Physical Exam

EZDERM provides a base package of dermatology-specific treatment plans that each provider can customize to their exact preference. Selecting and applying a treatment plan is going to be the first step for the clinical staff when entering the physical exam as it is what will populate the diagnosis and plan. So, what is a treatment plan exactly?

Treatment Plan: a plan that tells the system what CPT and ICD-10 Code should be generated as well as what text should populate in the following sections of the progress note:

• Morphology
• Differential diagnosis
• Assessment & Plan Notes
• Disorder Summary
• Consent
• Medications
• Laboratory Tests
• Imaging Tests
• Counseling notes
• Follow Up
• Procedure description and segments
• Additional Coding Information (Risk, Data Reviewed, and Problem Points)
• Billing Information (Turn off CPT code and/or add an item)

Each treatment plan will contain a different combination of the above sections that will depend on the specific Plan Type and diagnosis. So by selecting a particular treatment plan, you are applying all of the above sections as they are written in the treatment plan. If anything is different or unique for today's patient you always have the ability to edit any of the sections just for the particular note you are working on. 

How to Select a Treatment Plan to Apply a Diagnosis

1. Go into the Physical Exam section of a patient's progress note. 

2. At the top of the screen, you will see the Chief Complaint that was listed in the HPI section of the note (and you will be able to swipe to focus on different complaints if multiple have been added).

3. Below the complaint, you will see text that says "No Active Treatment Plan." Tap on the red plus sign icon next to this text to pull up a list of the provider's Treatment Plans. 

4. In the search bar at the top of the screen, type the name of the diagnosis or procedure you are looking for. The first line of the treatment plan name (in red) is called the Spoken Phrase. It will not show up anywhere in the note and can be customized per provider. The purpose of the spoken phrase is to give you more information about what is actually in the treatment plan.

For example, in the image below there are 2 treatment plans with similar names. The one difference is one states "Point Selection" the other "Area Selection." So what this is telling you is that you can either tap each individual lesion separately with the point selection plan or you can indicate a full area, such as the arm, and state you did multiple destructions.

5. The second line tells you how the treatment plan is going to code - specifically the plan type that pulls the CPT Code and the Diagnosis that pulls the ICD-10 code.

6. Once you find the treatment plan you would like to use, tap once on it to select it.

• If it is not a procedure and the locations were chosen in the HPI section you do not need to tap on the body map again. If the locations were not chosen in the HPI, tap on the body map to indicate a location. 
• If it is a procedure and the locations were indicated during the HPI section you will want to double tap on the existing tag where the location was indicated to apply it. You know the procedure has been applied because the text will change from the anatomical location to the procedure tag (the text that is in the parentheses shown above). If the locations were not chosen in the HPI you will just tap on your desired location(s) on the body map once to apply the plan. 

7. After either selecting the location or applying the procedure, the pie menu will appear allowing you to change many details of the problem or procedure.

At the top of the Physical Exam screen, the system will now show you the diagnosis that pulled from the selected treatment plan and you will see the treatment plan you chose listed right below that. 

Adding Additional Problems/Diagnoses

In order to add additional problems to the physical exam that were not documented as complaints in the HPI, tap on the red plus sign icon next to the complaint/diagnosis and you will see the following options to choose from:

• Assessment - Just diagnose the patient with a new problem and you will be able to select a clinical impression from the SNOMED database.
• Assessment and Plan - Pulls up a list of the provider's treatment plans for you to select from in order to fill in the details of the new problem. *This will be your most commonly selected option*
• Assessment with Complaint - Add a new complaint into the HPI section of the progress note and then indicate to the system what clinical impression you would like linked to that complaint.
• Assessment and Plan with Complaint - Add a new complaint into the HPI section of the progress note and then choose from the provider's list of treatment plans to diagnose and fill in the details of the new problem. 

Once you add a new problem and select the treatment plan you want to be associated with it, you will be brought back to the physical exam screen where you will need to document the location of the problem or procedure, which will once again allow you make any necessary changes via the pie menu. 

This new problem will be numbered at the top of the Physical Exam screen and you can swipe over the diagnosis to cycle between the different problems that have been documented for this patient. 

Deleting Diagnoses and Treatment Plans

If a problem/diagnosis was added to the patient's documentation in error, you can delete the problem in its entirety by tapping on the name of the problem or diagnosis at the top of the Physical Exam screen, which will show you a list of all diagnoses for the patient, and then swiping from right to left over the one you wish to delete. 

In order to delete just a treatment plan tied to a diagnosis and not the diagnosis itself, tap on the treatment plan selected (below the diagnosis) and swipe from right to left over that plan and tap the red Delete button that appears. Please note that if there is no other treatment plan tied to this diagnosis, the diagnosis will revert to a numbered "Finding."