Manage Assessment, Plan, and Orders
The Assessment and Plan area is where clinical judgment becomes operational work. It connects diagnoses, plan items, lab orders, imaging orders, prescriptions, and care team data.
What Assessment and Plan Each Do
Assessment
- Add diagnoses
- Manage diagnosis status
- Review AI-assisted suggestions
- Enter manual diagnoses
Plan
- Add medications, stock items, or services
- Adjust quantities and units
- Create external or internal diagnostic orders
- Connect prescribing and dispensing flows
- Record participating clinicians or nurses
Add Diagnoses
Step 1. Search or review suggested diagnoses
In Assessment, add diagnoses by searching standard terms or choosing from available suggestions.
Typical methods include:
- standard diagnosis search
- manual diagnosis entry
- AI-assisted diagnosis selection
Step 2. Set the diagnosis status
A diagnosis is not just a label. In repeat visits, ongoing, restored, or changed status matters for continuity.
Step 3. Leave an addendum if the chart is already completed
If the record is already completed, diagnosis changes follow an addendum or correction trail instead of ordinary editing.
Note: Post-completion diagnosis changes are audit-sensitive actions. Treat them as reason-required updates.
Add Plan Items
Plan can include several types of items:
- medications
- procedures or services
- stock items
- lab items
- imaging items
- custom items
Step 1. Choose an item from the catalog
Most plan items come from the catalog. Adding the same item again may increase quantity instead of creating a completely separate line.
Step 2. Adjust quantity and units
After selection, adjust values such as:
- quantity increase or decrease
- decimal-compatible quantities
- unit conversion or unit ratio behavior
Step 3. Use custom items when needed
If the standard catalog does not contain the item, a custom entry may be used. Operationally, standard catalog items are still better whenever possible because they keep billing and reporting more consistent.
Step 4. Connect medication to prescription or dispensing flow
Medication plan items can continue into prescription printing and dispensing. Distribution context such as IN_CLINIC or TAKE_HOME can also matter.
Lab and Imaging Orders
When diagnostic items are added to Plan, they can create downstream orders.
Lab order types
- Internal
- External
- Microscope
Imaging orders
Imaging items can connect into PACS or other image-order workflows.
Tip: Record the clinical reasoning first, then place the orders. That order of work makes later chart review and billing interpretation cleaner.
Why Plan Connects to Billing
Plan items are not just notes. They are also billing candidates. Because of that, editing can become restricted when:
- payments already exist
- a bill has already been issued
- some items are already in paid context
In OPD, existing payment history can reduce how much of the original plan remains editable. IPD may be more flexible operationally, but paid-item protection still matters.
Record Participating Staff
At completion time, the chart can also store participating veterinarians and nurses. In enterprise settings, this supports accountability and team-level analysis.
Practical Tips
- Do not let orders accumulate without clear Assessment entries.
- Quantity changes affect both billing and stock logic, so tie them to actual use.
- External lab and imaging work often have a different order date and result date. Set responsibility for result follow-up explicitly within the team.
What To Do Next
Once Assessment and Plan are complete, the visit can move toward completion, POS handoff, or later correction if needed.