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.

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