Adaptive Structure of the Progress Notes Builder

The progress note builder has an adaptive structure based on the service provided. Steps that are not relevant to a specific service are automatically hidden. For example, when documenting a service, the 'Podiatry Dx(s)' and 'Podiatry Procedure(s)' steps are excluded. Similarly, for a service, the 'Wound Assessment' and 'Wound Procedures' steps are excluded.

Steps	WT	GT	PD	GP
Patient's Encounter	✅	✅	✅	✅
Chief Complaint	✅	✅	✅	✅
History of Present Illness	✅	✅	✅*	✅
Medical History	✅	✅	✅	✅
Social History	✅	✅	✅	✅
Support Equipment	✅	✅	✅	✅
Review of Systems	✅	✅	✅	✅
Physical Exam	✅	✅	✅*	✅
Skin Exam	✅	✅	✅	✅
Additional Dx(s) / Finding	✅	✅		✅
Podiatry Dx(s)			✅
Wound Assessment	✅
Wound Procedures	✅
Other Procedure(s)	✅	✅	✅	✅
Podiatry Procedure(s)			✅
Encounter Complexity	✅	✅		✅
Assessment	✅*	✅	✅	✅
Recommendations	✅	✅	✅	✅
Treatment Plan	✅	✅	✅	✅
Orders	✅	✅	✅	✅
Next Visit	✅	✅*	✅	✅

Notes*

History of Present Illness

The Focused HPI field for the PD service is optional and does not require mandatory completion.

Physical Exam

When providing a PD service, additional blocks are made available for the provider to complete.

Assessment

When providing a WT service, additional blocks are made available for the provider to complete.