Creating Patient Notes

Note Type	Description
Chart	A chart note is an informal used to document financial information concerning a patient. Any number of items can be stored in this informal format.
Encounter	An encounter note is a type of chart note used to document information about an encounter. Any notation about an encounter is saved under the Encounter - Note section.
Quicknotes	A Quicknote is a shorter, less extensive note and is easily accessible on-line. It is attached to the chart.

Help Guide for NextGen® Enterprise PM 8

Create Quicknotes

Open NextGen® Enterprise PM. On the main toolbar, select Chart or Chart Lookup . The Patient Lookup window opens. In the Search Criteria section, enter the patient's information, and then select Find. Patient records that match the search criteria, appear in the Matching Records section. Select the patient, and then select Open. The Patient Chart window opens. Select the Clinical History/Notes tab. The Clinical History/Notes window opens displaying Topics and Description. Under the Topics section, select the category to attach the note and then right-click in the Descriptions section and select Quicknote. The Quicknote window opens. Enter a subject for the note. Select a description for the user note from the User Note Description list. Note: User Note Descriptions are automatically filled text items that you can select when you create a note. Enter a description for the note in Note Entry. Select OK. Note: NextGen® Enterprise PM timestamps the create date, author of the note, and any

Help Guide for NextGen® Enterprise PM 8

Viewing Clinical History and Notes Information

In the Clinical History/Notes tab of the patient's chart, you can view encounter and chart related information for the patient arranged in different topics. You can do the following on the Topics and Details section of the Clinical History/ Notes tab of the Patient Chart window: Select a topic under Clinical History to view any stored information Print a claim status report from Clinical History View existing recall plans for the patient Create a note or quick note for the patient's chart Attach any note or quick note to mail Seal a note or quick note View order notes for NextGen® Optical Management orders Clinical History/Notes Tab Creating Patient Notes You can use three types of patient notes to record formal or informal information for the patient. Create Quicknotes You can use the Clinical History/Notes window to create a Quicknote. Parent topic: Patient Encounters and Financial History

Help Guide for NextGen® Enterprise PM 8

Add Patient Quick Notes

You can add a quick note to add patient informal information to the patient chart. Then, you can send the quick note as mail to the patient, print, and fax, if needed. CAUTION: If a note is deleted, a significant event is not recorded in the patient's chart. Open NextGen® Enterprise PM. On the main toolbar, select Chart, and then in Patient Lookup, enter your search criteria, and then select Find. Matching people and patient records appear in the search results. In Matching Records, select a patient record , and then select Open. The Patient Information tab opens in the Patient Chart window. Select the Clinical History/Notes tab, and then in Topics, select Notes, and then select an encounter. Note: You can print the patient claim status report, and view the existing recall plans and order notes for NextGen® Optical Management orders in Clinical History/Chart Notes. Under Details, right-click and select New > Quicknote. In Quicknote, enter subject, description, and note information, and

Help Guide for NextGen® Enterprise PM 8

Attach Encounter or Chart Notes to Mail

You can attach an encounter note or chart note to a NextGen Mail message and send it to other users to enhance communication, reduce errors, and ensure traceability for documentation and follow-up. Open NextGen® Enterprise PM. Select Chart on the main toolbar, and then search and select the desired patient. The Patient Chart window opens. Select Chart on the main toolbar, and then search for and select the desired patient. In the Patient Chart window, do one of the following: Select the Clinical History/Notes tab, in the Topics list, select a topic with an existing quick note, and then select the note to be attached to a mail message from the Details section. Select the Encounters tab, in the Encounters list, select an encounter with an existing quick note, and then select the note to be attached to a mail message from the Encounter Notes section. Right-click and select Attach to Mail.The New Message window appears. The Subject field defaults to Chart Note or Patient Note - Enc #nnn an

Help Guide for NextGen® Enterprise PM 8

Add Notes to Encounters

Open NextGen® Enterprise PM. On the main toolbar, select Chart or Chart Lookup . The Patient Lookup window opens. In the Search Criteria section, enter the patient's information, and then select Find. Patient records that match the search criteria appear in the Matching Records section. Select the patient, and then select Open. The Patient Chart window opens. Select Encounters and then select the Notes tab under it. The Encounters and Encounter Notes sections appear. Under the Encounters section, select an encounter. Select open record and then select New. The Patient Note window opens. Patient Notes Window Enter details in Subject and Note Entry section, and then select OK. Note: You can select the Seal Note check box to seal and keep a note confidential. A pushpin appears on the Note tab along with the number of added encounters. Parent topic: Viewing Notes Information in Encounters

Help Guide for NextGen® Enterprise PM 8

Modify or Delete a Patient Quick Note

Open NextGen® Enterprise PM. On the main toolbar, select Chart, and then in Patient Lookup, enter your search criteria, and then select Find. Matching people and patient records appear in the search results. In Matching Records, select a patient record , and then select Open. The Patient Information tab opens in the Patient Chart window. Select the Clinical History/Notes tab, and then in Topics, select Notes, and then select an encounter. To unlock a note, right-click the note, select Unseal, enter your NextGen® Enterprise credentials, and then select OK. To update a note, double-click the note, update the necessary information, and then select OK. To delete a note, right-click the note, and then select Delete. Optional: To view clinical information, in Topics, select the corresponding topic. Parent topic: Add Patient Quick Notes

Creating Patient Notes

Recommendations

Create Quicknotes

Viewing Clinical History and Notes Information

Add Patient Quick Notes

Attach Encounter or Chart Notes to Mail

Add Notes to Encounters

Modify or Delete a Patient Quick Note

Creating Patient Notes

Create Quicknotes

Viewing Clinical History and Notes Information

Add Patient Quick Notes

Attach Encounter or Chart Notes to Mail

Add Notes to Encounters

Modify or Delete a Patient Quick Note