Document the Patient's Comprehensive Clinical and Nursing Details
Open NextGen® Enterprise EHR, and then in Patient History, select Open Templates.
The Select Template window opens.
On the Medical Records tab, select All.
Select Nursing Note (BH), and then select OK.
In the Time Entry Navigation sidebar, select Billing Time Entry, and then enter the start time.
Note: You can select the current time or enter the time manually.
Select the program.
In the Individuals Present panel, document the details of the individuals present during the assessment.
In the Vital Signs panel, select Add to capture the patient's vitals.
In the New Issues panel, document the patient's new issues and the status.
In the Risk Assessment panel, document the patient's risks towards suicide or danger to self or properties.
Document whether the patient takes medication as prescribed.
Document the patient's alleries and their current status.
Enter your plan and discussion on the patient's treatment.
Note: You can select Copy Forward to copy existing details from another encounter to the current encounter.
Document the patient's assessment and diagnosis details.
Document the applicable signatures from the tasking supervisor or staff.
In the Orders panel, document the patient's lab, radiology, and medication orders.
Document interim updates on the patient's medication and progress towards the symptoms.
In the Current Assessment panel, document the current status of the patient's mood, motor activities, behavior, and medical condition.
In the Goals, Objectives, and Interventions Addressed Today panel, document the patient's goals, objectives, and interventions addressed on the current date.
Review and document the patient's current symptoms towards social and developmental history.
Examine and document the patient's physical details.
In the Time Entry Navigation sidebar, select Billing Time Entry, and then enter the end time.
Note: You can select the current time or enter the time manually.
In the Charges panel, document the billing details.
Optional: Select No Billing for Service if there is no charge for the current date.
