WoundAlly
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  • QA Portal
    • Progress Notes
  • Provider Portal
    • Settings Tab
  • Progress Note Builder
    • Adaptive Structure of the Progress Notes Builder
    • How to create a Progress Note?
    • Progress Note Statuses
    • Progress Note Builder
      • Patient's Encounter
      • Chief Complaint
      • History of Present Illness
      • Medical History
      • Social History
      • Support Equipment
      • Review of Systems
      • Physical Exam
      • Skin Exam
      • Patient Assessment
      • Wound Assessment
      • Wound Procedures
      • Dressing
      • Other Procedure(s)
      • Additional Dx(s) / Finding
      • Encounter Complexity
      • Assessment
      • Treatment Plan
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    • Progress Note Tools
      • Description Templates
      • ICD 10 integration
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    • Group Settings
      • Main Settings
      • Progress Note Tab
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    • Deleting a Patient's Medical Record.
    • Removing a Progress Note
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  • Notes*
  • History of Present Illness
  • Physical Exam
  • Assessment

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  1. Progress Note Builder

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.

PreviousSettings TabNextHow to create a Progress Note?

Last updated 3 days ago

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